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RC46  .B28  A  treatise  on  the  pr 


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/ 


A  TREATISE 


PRACTICE  OF  MEDICmE, 


TI8E  OF  STUDENTS  AND  PRACTITIONERS. 


BY 

ROBERTS  BARTHOLOW,  M.  A.,  M.  D.,  LL.  D., 

Professor  of  Materia  Medica  and  General  Therapeutics  in  the  Jefferson  Medical  College  of 

Philadelphia;  formerly  Professor  of  the  Theory  and  Practice  of  Medicine  and  of  Clinical 

Medicine  in  the  Medical  College  of  Ohio;  Fellow  of  the  College  of  Physicians  of 

Philadelphia;  Member  of  the  American  Philosophical  Society;  Honorary 

Member  of  the  Medical  and  Chirurgical  Faculty  of  Maryland,  of  the 

Ohio  State  Medical  Society,  of  the  Cincinnati  Academy  of 

Medicine,  of  the  New  York  Neurological  Society; 

President  of  the   American   Neurological 

Association,  etc. 


ISTEW    YORK: 
D.     APPLETON    AND    COMPANY, 

1,   3,    AND   5   BOND    STREET. 
1880. 


COPYRIGHT  BT 

D.  APPLETON  AND  COMPANY. 


THIS  WORK, 
THE    FIEST   PRODUCT    OF    MY    LABOR   IN   PHILADELPHIA, 

WITH   AFFECTIONATE   REGARD, 
TO    THE    PRESIDENT,    TRUSTEES,    AND    FACULTY 

OF 

JEFFERSON  COLLEGE. 


P  E  E  F  A  C  E . 


In  undertaking  the  preparation  of  a  treatise  on  the  Practice  of 
Medicine,  I  had  the  intention  to  write  a  companion  volume  to  my 
work  on  Materia  Medica  and  Therapeutics.  When  announced,  the 
book  was  so  far  advanced  that  its  completion  was  confidently  anti- 
cipated within  the  year.  Unfortunately,  the  condensation  of  mate- 
rial found  necessary,  when  the  work  had  reached  that  stage  where 
its  proportions  could  be  judged  with  some  accuracy,  involved  much 
additional  labor.  This  was  the  more  regrettable,  as  the  incessant 
demands  of  a  large  private  practice  and  the  onerous  duties  of  an 
exacting  professorial  position  permitted  little  of  that  uninterrupted 
leism-e  which  is  essential  for  successful  literary  composition.  Slow 
progress  was  inevitable  under  these  circmnstances,  and  hence  it  was 
not  until  my  removal  to  Philadelphia  last  year  that  I  could  devote 
some  hours  each  day  to  my  arduous  task.  I  trust  that  this  explana- 
tion of  the  delay  in  the  appearance  of  the  treatise  will  be  satisfac- 
tory to  my  readers,  especially  to  the  large  number  who  have  hon- 
ored me  by  subscribing  for  the  work  long  in  advance  of  its  publi- 
cation. 

As  my  treatise  on  Materia  Medica  and  Therapeutics  embraced 
those  topics  of  importance  to  the  physician,  and  omitted  matters  of 
rather  extraneous  interest,  so  in  the  preparation  of  this  volume  my 
purpose  was  to  include  the  subjects  embraced  under  the  title  of 
"  Practice  of  Medicine,"  omitting  those  topics  of  general  pathology, 
etiology,  etc.,  with  which  the  works  on  Practice  usually  open,  and 


yi  PREPACE. 

whicli,  thougli  siifSciently  valuable  in  themselYes,  are  too  often 
passed  over  hastily,  or  not  read  at  all,  in  tlie  desire  to  reacli  tlie 
practical  subjects.  I  have  therefore  omitted  the  topics  in  question 
from  their  position  as  an  introduction  to  special  pathology,  and 
have,  although  at  the  disadvantage  of  some  repetition,  incoi-porated 
them  in  their  proper  relation  with  individual  diseases. 

That  I  should,  under  all  the  circumstances  above  stated,  have 
undertaken  such  a  task  as  the  preparation  of  this  treatise,  for  which, 
it  may  be  suggested,  there  was  no  special  need,  and,  if  the  need  ex- 
isted, there  was  no  claim  on  me  to  supply  it,  may  be  accounted  for 
by  the  fact  that,  when  the  work  was  begun,  I  was  Professor  of  the 
TheoiT  and  Practice  of  Medicine  and  of  Clinical  Medicine  in  the 
Medical  College  of  Ohio,  and  was  ui'ged,  not  only  by  the  students 
and  practitioners  who  attended  my  lectures,  but  also  by  many  read- 
ers of  my  therapeutical  treatise,  to  prepare  a  volume  on  Practice, 
which  should  have  the  practical  characteristics,  the  definiteness  of 
statement,  the  conciseness,  and.  at  the  same  time,  the  fullness  of 
the  work  on  Materia  Medica  and  Therapeutics.  I  was  the  more 
inclined  to  accede  to  these  wishes  because  of  a  natural  desire  to  ap- 
pear as  an  author  on  subjects  to  which  I  had  devoted  all  the  years 
of  my  professional  life,  and  under  the  most  varied  conditions. 
Serving  as  an  officer  of  the  medical  stafE  of  the  ITnited  States  Army 
in  Kansas,  Utah,  Colorado,  Xew  Mexico,  Minnesota,  and  during  the 
war  of  the  rebellion  at  "Washington,  Xashville,  Chattanooga,  Balti- 
more, etc.,  followed  by  an  extensive  practice  (private  and  hospital) 
of  sixteen  years  at  Cincinnati,  I  may  justly  claim  to  have  enjoyed 
large  opportunities  for  the  clinical  study  of  the  diseases  of  the 
Xorth  American  Continent.  "With  one  or  two  unimportant  excep- 
tions, I  have  had  personal  charge  of  the  maladies  treated  of  in  this 
work,  and  have  made  them  the  subject  of  clinical  demonstration 
and  jpost-mortern  investigation,  either  privately  or  in  public  lectures. 

In  the  treatment  of  the  various  topics,  I  have  attempted  to  give 
to  each  just  that  amount  of  consideration  to  which  its  importance 
entitles  it,  within  the  limitations  imposed  by  the  size  of  the  work. 
A  just  harmony  and  proportion  can  be  secured  only  by  condensing 
some  subjects  and  displaying  others,  ^o  space  has  been  given  to 
merely  historical  disquisitions,  or  to  the  discussion  of  controverted 


PREFACE.  y{{ 

points.  Also,  to  utilize  all  available  sj^ace,  chapters  have  been  dis- 
j)ensed  with,  and  the  intervals  between  the  sections  have  been  ab- 
breviated as  much  as  possible.  ^Notwithstanding  my  utmost  efforts 
at  condensation,  the  work  has  grown  beyond  the  contemplated  size ; 
but  I  would  fain  hope  that  no  part  of  it  could  be  sacrificed  without 
impairing  the  value  of  the  whole. 

Much  of  the  matter  embraced  in  a  work  of  this  kind  is  the 
common  property  of  the  medical  profession,  and  hence  I  have  not 
quoted  many  authorities.  I  have  rather  avoided  references  when 
their  mention  would  have  been  mere  pedantry,  and  would  have 
occupied  valuable  space.  IS^evertheless,  when  I  was  distinctly  in- 
debted for  some  fact  or  opinion,  I  have  given  the  reference  to  the 
authority.  Sometimes,  when  the  authority  is  well  known,  the 
name  is  merely  inclosed  in  parentheses.  It  is  a  comparatively  easy 
task,  especially  with  the  aids  now  at  our  disposal,  to  give  an  ex- 
tended bibliography,  but  the  space  occupied  would  have  swollen 
this  work  to  encyclopedic  proportions,  without  adding  to  its  real 
utility.  When  an  author  only  expresses  the  opinions  of  his  author- 
ities, he  avoids  the  appearance  of  dogmatism,  which  must  be  the 
tone  of  a  work  giving  utterance  to  individual  opinions ;  but  I  could 
hardly  do  otherwise  than  draw  my  clinical  material — the  descrip- 
tions of  diseases — from  my  own  observations  at  the  bedside.  Also, 
a  large  experience  in  the  treatment  of  disease  could  not  fail  to 
develop  some  positive  convictions  as  to  the  real  value  of  remedies. 
The  reader  will  find  that  I  have  no  sympathy  with  the  therapeu- 
tical nihilism  of  the  day,  and  that  my  convictions  find  expression 
in  the  recommendation  of  plans  of  treatment.  In  a  work  of  this 
kind,  intended  for  the  guidance  of  young  practitioners  and  students, 
some  dogmatism,  although  offensive  to  the  highest  taste,  may  be 
pardoned,  in  view  of  the  practical  advantages  of  experienced  leader- 
ship. Indeed,  there  is  no  department  of  the  subject  in  which  it 
seemed  to  me  so  necessary  to  express  positive  opinions.  The  influ- 
ence of  some  of  our  most  prominent  medical  thinkers  has  been 
opposed  to  the  value  of  medicines  in  the  treatment  of  disease. 
The  modern  school  of  pathologists,  absorbed  in  the  contemplation 
of  the  ravages  of  diseases,  are  either  oblivious  of  the  curative 
powers  of  remedies,  or  openly  ridicule  the  pretensions  of  thera- 


■y^jjj  PREFACE. 

peutists.  I  have,  therefore,  in  the  therapeutical  sections,  especially 
endeavored  to  set  forth  true  principles,  and  have  taught  the  utility 
of  drugs  when  rightly  administered,  but  have  none  the  less  tried 
to  indicate  the  limits  of  their  utility,  for  he  who  is  unmindful  of 
the  injury  done  by  ill-directed  or  reckless  medication  is  as  unsafe  a 
guide  as  the  most  pronounced  therapeutical  nihilist. 

The  pathological  doctrines  inculcated  in  the  work  are  derived 
from  the  highest  sources.  The  few  illustrations  of  morbid  changes 
introduced  were  obtained  from  the  admirable  atlas  of  Thierfelder. 
As  my  information  on  this  subject  was  derived  from  those  best 
qualified  to  instruct,  I  have  not  hesitated  to  express  with  some 
decision  the  present  state  of  knowledge  in  resj^ect  to  the  pathology 
of  the  various  diseases,  desiring  in  this,  as  in  other  departments  of 
my  subject,  to  give  some  positive  views.  I  may  be  criticised  with 
the  observation  that,  in  the  progress  of  discovery,  the  doctrines  at 
present  received  unreservedly  may  be  entirely  overthrown,  and 
very  different  views  be  substituted.  It  will  be  time  enough,  how- 
ever, when  the  change  comes,  to  adapt  our  opinions  to  the  new 
order  of  pathological  doctrines. 

Having  thus  explained  my  intentions  in  producing  the  work, 
I  submit  it  to  the  judgment  of  the  medical  profession,  with  the 
assurance  that,  whether  favorable  or  unfavorable,  the  decision  will 
be  just. 

Roberts  Baetholow. 

1509  Walnut  Street,  Philadelphia, 
September,  1880. 


TABLE    OF    COI^TEj^TS. 


SPECIAL  PATHOLOGY  AND   THERAPEUTICS. 


Diseases  of  the  Digestite  System 
Stomatitis 

Aphthous 

Muguet 
Glossitis 

Superficial   . 

Deep 
Gangrene  of  the  Mouth  . 
Noma 

Catarrh  of  Xaso-pharyngcal  Mucous 
Catarrh  of  Lower  Pharynx 
Retro-pharyngeal  Abscess 
Diseases  of  the  CEsophagcs 
CEsophagitis 
Dysphagia 

Stenosis  of  the  (Esophagus 
Dilatations  of  the  (Esophagus 
Diseases  of  the  Stomach 
Acute  Gastritis 
Toxic  Gastritis    . 
Phlegmonous  Gastritis 
Chronic  Gastric  Catarrh 
Atonic  Dyspepsia 
Gastralgia 

Ulcer  of  the  Stomach 
Carcinoma  of  the  Stomach 
Hfematemesis 
Dilatation  of  the  Stomach 
Diseases  or  the  Intestine 
Catarrh  of  the  Intestine 
Cholera  Morbus 

Infantum 
Duodenitis     . 
Ileitis 
Ileo-colitis     . 


Membrane 


?ASE 
1 


5 
5 

1 
1 
9 
11 
12 
13 
13 
14 
15 
16 
\1 
18 
21 
20 
23 
29 
30 
33 
41 
49 
53 
55 
55 
57 
60 
64 
67 
67 


COXTENTS. 


Tvplilitis  .... 

Inflammation  of  the  Appendix  Yermiformis 
Perityphlitis        .... 
Proctitis — Catarrh  of  the  Rectum  . 
Croupous  Enteritis 
Dysentery   .... 
Ulcers  of  the  Intestines 
Cancer  of  the  Intestines 
Intestinal  Haemorrhage 
Enteralgia  .  .  .  , 

Obstruction  of  the  Intestines    . 
Intestinal  Parasites 

Cestoda 

Taenia  Solium  . 

Tcenia  Saginata 

Eothriocephalus  Latus 

Xematoda  . 

Ascaris  Lumbricoidcs 
Osyurus  Yermicularis 
Trichocephalus 
Diseases  of  the  Peritoneum 

Peritonitis  .... 
Ascites 
Diseases  of  the  Pancreas    . 
Pancreatitis 
Cancer  of  the  Pancreas 
Cysts  of  the  Pancreas  . 
Calculi         .... 
Diseases  of  the  Liter  . 
Congestion  of  the  Liver 
Interstitial  Hepatitis 
Sclerosis      .... 
Abscess  of  the  Liver     . 
Acute  Yellow  Atrophy 
Amyloid  Liver  . 
Carcinoma  of  the  Liver 
Echinococcus  of  the  Liver 
Aneurism  of  the  Hepatic  Artery     . 
Thrombosis  of  the  Portal  Yein 
Suppurative  Pylephlebitis   . 
Catarrh  of  the  Bile-Ducts 
Occlusion  of  the  Biliary  Passages  . 
Biliary  Calculi  . 
Diseases  of  the  Spleen 
Acute  Splenitis 
Enlargement  of  the  Spleen 
Misplaced  Spleen 

Amyloid  Degeneration  of  the  Spleen 
Echinococcus  of  the  Spleen 
Diseases  of  the  Blood-forming  Organ- 
Leucocythemia  . 
Melansemia .  . 


PAGE 

69 
.  14 
74 
Yo 
79 
82 
91 
96 
99 
100 
102 
113 
114 
114 
116 
119 
120 
120 
123 
124 
125 
125 
132 
136 
137 
138 
140 
140 
140 
140 
145 
145 
151 
161 
165 
169 
172 
178 
178 
179 
180 
184 
185 
189 
189 
191 
192 
193 
193 
194 
194 
200 


CONTENTS. 


XI 


page 

Haemophilia      ...            =            .,. 

201 

Scorbutus    .            . 

.     205 

Purpura             ....... 

210 

Ana?mia       ........ 

.     213 

Chlorosis            ....... 

219 

Progressive  Pernicious  Anaemia       ..... 

.     222 

Thrombosis  and  Embolism        .             .            .            .            . 

224 

Diseases  of  the  Heart         ...... 

.     228 

Pericarditis        ....... 

228 

Adhesions  of  the  Pericardium         ..... 

.     238 

Hydropericardium         ...... 

240 

Myocarditis              ....... 

.     242 

Fatty  Degeneration        ...... 

245 

Rupture  of  the  Heart          ...... 

.     248 

Hypertrophy  and  Dilatation      ..... 

248 

Plastic  Endocarditis             .             .             . 

.     256 

Ulcerative  Endocarditis             ..... 

260 

Diseases  of  the  Valves  and  of  the  Orifices 

.     264 

Affections  of  the  Aortic  Valves  and  Orifice 

269 

Affections  of  the  Mitral  Valves  and  Orifice 

.     272 

Affections  of  the  Tricuspid  Valves  and  Orifice. 

275 

Affections  of  the  Pulmonary  Valves  and  Orifice 

.     277 

Heart-Clots        ....... 

283 

Palpitation  of  the  Heart     ...... 

.     285 

Diseases  of  the  Blood-Vessels             .            .            :            . 

287 

Arteritis      ........ 

.     287 

Aneurism  of  the  Aorta               ..... 

291 

Diseases  of  the  Respiratory  Organs         .... 

.     304 

Pleuritis             ....... 

304 

Hydi'othbrax            ....... 

.318 

Pneumothorax  .             .             . 

320 

Hydropneumothorax            ...... 

.     320 

Pneumonia        ....... 

325 

Embolic  Pneumonia             ...... 

.     341 

Catarrhal  Pneumonia     ...... 

343 

Phthisis  Pulmonalis             ...... 

.     350 

Caseous      ....... 

350 

Tubercular       ....... 

.     355 

Fibroid      ....             ... 

363 

Hasmoptysis             .             .             .    '         , 

.     373 

Hyperaemia  and  (Edema             ..... 

379 

Atelectasis  ........ 

.     383 

Gangrene           ....... 

394 

Carcinoma  ........ 

.     398 

Echinococci       ....... 

400 

Acute  Bronchitis     ....... 

.     402 

Chronic  Bronchitis 

407 

Croupous  Bronchitis             ...... 

.     411 

Stenosis  of  Trachea  and  Bronchi          .            .            ,            „ 

415 

Asthma        ........ 

.416 

Diseases  of  the  Larynx            ..... 

422 

Acute  Laryngitis     .             .             .             , 

.     422 

Xll 


CONTENTS. 


PAGE 

Chronic  Laryngitis         ...... 

424 

(Edema  of  the  Glottis          ...... 

.     426 

Laryngismus  Stridulus               ..... 

429 

Croupous  Laryngitis  (True  Croup)              .... 

.     431 

Coryza  .             .             .             .             .      •       . 

437 

Epistaxis     ........ 

.     439 

Diseases  of  the  Kidney             ..... 

441 

Congestion  of  the  Kidneys,  active  . 

.     441 

Congestion  of  the  Kidneys,  passive      .... 

442 

Acute  Parenchymatous  Nephritis    ..... 

.     443 

Acute  Parenchymatous  Nephritis  of  Pregnancy 

448 

Chronic  Parenchymatous  Nephritis              .... 

.     450 

Interstitial  Nephritis     ...... 

454 

Amyloid  Kidney      ....... 

.     461 

Pyehtis  and  Pyelonephritis 

466 

Eenal  Calculi           ....... 

.     469 

Hydronephrosis              ...... 

476 

Carcinoma  of  the  Kidney    ...... 

.    478 

Tuberculosis  of  the  Kidney       ..... 

481 

Echinococcus  of  the  Kidney            ..... 

.     482 

Movable  Kidney             ...... 

485 

Perinephritis            .             .             .             .             .             ... 

.     487 

Diseases  of  the  Nervous  System          .... 

489 

Cerebral  Hypersemia            .             .             .             .             .             . 

.     489 

Ansemia      ....... 

493 

Occlusion  of  the  Cerebral  Vessels  ..... 

.     496 

Obliteration  of  the  Capillaries       .... 

501 

Occlusion  of  the  Sinuses          ..... 

.     502 

Cerebral  Hsemorrhage  ...... 

604 

Meningeal        ....... 

.     511 

Pachymeningitis             ...... 

512 

Externa            ....... 

.     512 

Interna      ....... 

512 

Acute  Hydrocephalus          ...... 

.     515 

Chronic  Hydrocephalus              .             .             . '           . 

517 

Congenital  Hydrocephalus  ...... 

.     518 

Tubercular  Meningitis  ...... 

520 

Acute  Meningitis     .             .             .             . 

.     524 

Chronic  Meningitis         ...... 

527 

Abscess  of  the  Brain           .             .             .             . 

.     528 

Intra-cranial  Tumors     ...... 

532 

Aphasia       ........ 

.     538 

Diseases  of  the  Medulla  Oblongata   .... 

541 

Haemorrhage  in  the  Medulla            ..... 

.     541 

Occlusion  of  the  Vessels  of  the  Medulla 

543 

Acute  Inflammation  of  the  Medulla  (Acute  Bulbar  Paralysis) 

.     543 

Chronic  Inflammation  of  the  Medulla  (Chronic  Progressive  Bulbar  ] 

'aralysis) .            544 

Diseases  of  the  Spinal  Meninges  and  Cord 

.     548 

Hypersemia  of  the  Spinal  Cord              .... 

548 

Spinal  Meningeal  Hasmorrhage 

.     550 

Pachymeningitis  Spinalis           ..... 

552 

Spinal  Meningitis    ....... 

.     553 

CONTENTS. 


xm 


Acute  Myelitis  .  .  •  • 

Chronic  Myelitis 

Posterior  Spinal  Sclerosis  (Progressive  Locomotor  Ataxia) 

Lateral  Spinal  Sclerosis  (Spastic  Spinal  Paralysis' 

Infantile  Paralysis 

Progressive  Muscular  Atrophy 

Pseudo-Hypertrophic 
Multiple  Sclerosis  of  the  Brain  and  Cord 
Dementia  Paralytica     . 
Syphilis  of  the  Nervous  System 

Cerebral  Syphilis   . 

Spinal  Syphilis 

Of  the  Nerves 
Ckrebro-spinal  Neuroses 

Epilepsy  .... 

Hysteria       .... 
Catalepsy  .... 

Paralysis  Agitans    . 
Chorea  ..... 
Writer's  Cramp 

Tetanus  .... 

Diseases  of  the  Peripheral  Nerves 
Neuritis  .... 

Atrophy  of  the  Nerves 
Neuralgia  .... 

Tic-Douloureux 

Cervico-occipital    . 

Cervico-brachial 

Intercostal 

Lumbo-abdominal 

Sciatica      .... 
Convulsive  Tic  (Histrionic  Spasm)  . 
Torticollis  (Wry  Neck) 
Spasm  of  the  Diaphragm  (Singultus) 
Paralysis  of  the  Ocular  Muscles 
Facial  Paralysis 

Vaso-motor  and  Trophic  Neuroses 
Hemicrania  (Migraine) 
Angina  Pectoris 
Exophthalmic  Goitre  (Graves's  Disease) 


GENERAL   OR   CONSTITUTIONAL  DISEASES. 
Eruptive  Fevers 
Variola . 

Confluens 
Hsemorrhagica 
Varioloid     . 
Vaccinia  and  Vaccination 


Varicella 
Rubeola  (Measles) 
Roseola  (Roetheln) 
Scarlatina — Scarlet  Fever 


PAGE 

557 

561 

564 

571 

573 

576 

580 

581 

585 

590 

590 

593 

595 

595 

595 

603 

611 

612 

615 

618 

620 

624 

624 

626 

626 

626 

630 

630 

630 

630 

631 

635 

636 

638 

639 

640 

642 

642 

644 

646 


649 
649 
657 
658 
659 
662 
665 
666 
672 
673 


XiY                                                            CONTENTS. 

PAGE 

Diagnosis  of  the  Eruptive  Fevers    .            .            .            . 

.     683 

Erysipelas         .            . 

684 

Fevkks             .            .            .            .            .            .            . 

.     689 

Typhoid  Fever  ....... 

689 

Typhus        ....... 

.     705 

Kelapsing  Fever            .            .             .             . 

'710 

Yellow  Fever           ...... 

.     715 

Dengue.            ....... 

724 

Miasmatic  Diseases  ...... 

.     727 

Cholera              .             .             .             .             .             . 

727 

Diphtheria  ....... 

.     736 

Cerebro-spinal  Meningitis          ... 

.        '    .           751 

Influenza  (Epidemic  Catarrh)          .... 

.     761 

Hay-Fever  (Summer  Catarrh)    .             .             .             .             . 

764 

Whooping-Cough  (Pertussis)            .... 

.     768 

Parotiditis  (Mumps)      ...... 

771 

Malarial  Diseases    ...... 

.    774 

Intermittent  and  Remittent  Fevers       .            ,            .            . 

774 

Disorders  of  Nutrition        ..... 

.     790 

Scrofula             ....... 

790 

Acute  Miliary  Tuberculosis              .       ,     . 

.     795 

Eickets              ...,., 

798 

Lymphadenoma                   ,,..., 

.     804 

Acute  Rheumatism        ....,, 

809 

Chronic  Rheumatism           .             ,             .             .             , 

.     817 

Gout  (Podagra)              .             ,             . 

819 

Arthritis  Deformans        .           ^     , 

.     825 

Diabetes  Mellitus 

'       .            .           828 

Diabetes  Insipidus               „<,... 

.     837 

Animal  Poisons  ....... 

839 

Hydrophobia            ...... 

.     839 

Parasites             ....... 

848 

Trichinae  and  Trichinosis                 .... 

.     843 

LIST   OF   ILLUSTEATIOI^S. 


FIG. 
1. 

2. 
3. 
4. 
5. 
6. 
7. 


10. 
11. 
12. 
13. 
14. 
15. 


16. 
11. 
18. 
19. 
20. 
21. 
22. 
23. 
24. 
25. 
26. 
27. 
28. 
29. 
80. 
31. 
.32. 
33. 
34. 
35. 


PAGE 

Torsion  of  the  Intestine         .......  103 

Constriction  of  the  Intestine  by  a  Band  of  False  Membrane      .  .  .      103 

Teenia  Solium  ........  115 

Scolex  of  Taenia  .........      115 

Bothriocephalus  Latus  .  .  .  .  .  .  .  115 

Bothriocephalus  Latus,  Egg  of    .  .  .  .  .  .  .115 

Bothriocephalus  Latus,  Scolex  of      .  .  ,  .  .  .  116 

Ascaris  Lumbricoides      .  .  .  .  .  .  =  .120 

Tricocephalus  Dispar  ........  123 

Oxyurus  Vermicularis      .  .  .  .  c  .  .  .123 

Area  of  Hepatic  Dullness  in  Cancer  of  the  Liver      .  ,  .  .  171 

Scolex  of  Taenia  Echinococcus     .......      174 

Taenia  Echinococcus  of  the  Pig         ......  174 

Taenia  Echinococcus  of  the  Dog  .  .  .  .  .  .  .174 

Enlargement  of  the  Liver  by  Hydatids         .....  175 

Relation  of  the  Valves  and  Orifices  of  the  Heart  to  the  Ribs,  Sternum,  and 

Exterior  .......        To  face       228 

Effusion  into  the  Sac  of  the  Pericardium  .....      233 

Sphygraographic  Tracing  in  Hypertrophy  of  the  Heart         .  .  .  251 

Sphygmographic  Tracing  in  Aortic  Stenosis        .....      269 

Sphygmographic  Tracing  in  Aortic  Insufiiciency       ....  270 

Sphygmographic  Tracing  in  Mitral  Stenosis        .  .  .  -  ,      273 

Sphygmographic  Tracing  in  Mitral  Insufficiency       .  ,  .  .  274 

Pleurisy  with  Effusion     ...-..-.      311 
Hydropneumothorax  .  .  ,  .  .  ■  322 

Fibrous  Tissue  in  Sputa  ........      330 

Temperature  Range  in  Pneumonia  (Crisis)  .....  333 

Temperature  Range  in  Pneumonia  (Lysis)  .....      334 

Caseous  Pneumonia  ........  352 

Temperature  Range  in  Caseous  Pneumonia         .  .  .  .  .354 

Miliary  Tuberculosis  .  .  .  .  .  .  .  356 

Fragment  of  Lung-Tissue  and  Sputa       ......      361 

Cavities  ;  one  pai'tly  filled,  one  empty  .....  365 

Casts  in  Acute  Parenchymatous  Nephritis  .....      446 

Epithelium  from  Convoluted  Tubes  ......  446 

Casts  in  Chronic  Parenchymatous  Nephritis        .  .  .  .  .451 

Casts  becoming  fatty  .  .  .  .  .  .  .  451 


XVI 


ILLUSTRATIONS. 


Fra.  PAGE 

36.  Hyaline  Casts       .  .  .  .  .  .  .  .  .      464 

37.  Various  Forms  in  Pj'elitis     .  .  ...  .  .  .  468 

38.  Various  Forms  in  Urinary  Deposits         ....  .  .  .      472 

No.  1.  Uric  Acid. 

2.  Urate  of  Soda. 

3.  Cystine. 

4.  Oxalate  of  Lime. 

5.  Dumb-bell  Oxalate  of  Lime. 

39.  Epithelium  of  the  Kidney     .  .  .  .  .  476 

No.  1.  Of  the  Ureter. 
2.  Of  the  Urethra. 

40.  Temperature  in  Discrete  Variola  ......      654 

41.  Temperature  in  Coherent  Variola     ......  655 

42.  Temperature  in  Confluent  Variola  ......      658 

43.  Temperature  in  Uncomplicated  Measles        .....  668 

44.  Temperature  in  Measles  with  Catarrhal  Pneumonia        ....      670 

45.  Temperature  in  Typhoid  Fever  .  .  ,  .  .  .  697 

46.  Temperature  in  Acute  Miliary  Tuberculosis        .....      796 


SPECIAL  PATHOLOGY  AND  THERAPEUTICS, 


DISEASES  OE  THE  DIGESTIVE  SYSTEM. 


STOMATITIS. 

Definition. — Stomatitis  is  an  inflammation  of  the  buccal  mucous 
membrane.  There  are  various  forms  of  the  disease,  determined  by  the 
seat  and  character  of  the  lesion — for  example  :  simple,  follicular  or 
aphthous,  ulcerative,  mercurial,  and  parasitic. 

Causes. — Simple  stomatitis  may  be  a  part  of  a  catarrhal  process 
which  involves  the  mouth,  the  oesophagus,  and  the  stomach  ;  but  more 
frequently  it  is  caused  by  local  irritants,  such  as  condiments,  tobacco, 
too  hot  and  too  cold  liquids,  etc.  The  follicular  or  aphthous  form 
occurs  at  all  ages,  but  is  more  common  in  early  life.  Children  having 
feeble  constitutions  depressed  by  bad  hygienic  influences  are  especially 
liable.  Often  dependent  on  gastro-intestinal  disorders,  it  is  a  frequent 
complication  of  prolonged  diarrhcea,  and  more  certainly  so  when  the 
stools  have  an  acid  reaction.  The  ulcerative  form  is  due  to  all  those 
causes,  also,  which  depress  the  vital  forces — to  fatigue,  to  excesses  of 
all  kinds,  to  bad  hygiene,  to  damp  and  dark  habitations,  to  improper 
and  insuflicient  food,  and  to  various  cachexise.  Mercurial  stomatitis  is 
produced  by  the  systemic  action  of  mercury,  in  what  form  or  mode 
soever  the  metal  may  be  introduced  into  the  organism.  It  should  be 
remembered  that  in  infancy  the  mercurial  action  does  not  manifest 
itself  in  stomatitis,  but  in  an  equally  injurious  toxic  action  of  another 
form. 

Symptoms. — It  is  almost  invariably  true  of  inflammation  of  a  mu- 
cous membrane,  that  the  first  effect  of  the  process  is  to  arrest  secretion 
of  its  glandular  appendages.  The  membrane  becomes  rough  and 
swollen,  and  of  a  vivid  red  color  ;  and  the  glands,  especially  those  at 
the  base  of  the  tongue,  by  an  increase  of  their  contents,  enlarge  and 
become  prominent  ;  but  the  dryness,  in  a  few  hours,  is  succeeded  by 
increased  secretion.  The  fluid  now  poured  out  from  the  surface  of  the 
1 


2  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

mucous  membrane  consists  of  a  transparent  solution — serum — holding 
in  suspension  numberless  young  cells,  cast-off  epitbelium  undergoing 
fatty  metamorphosis,  and  minute  organisms,  bacteria,  etc.,  derived 
from  the  external  air.  The  exuded  fluid  tends  to  accumulate  at  cer- 
tain points  in  the  cheeks  and  on  the  gums,  and  on  the  floor  of  the 
mouth.  In  some  places,  especially  at  the  mouths  of  the  follicles, 
superficial  erosions  are  produced  by  the  falling  off  of  the  epithelium. 

The  mouth  feels  dry  and  hot  at  the  outset.  Considerable  pain  is 
experienced  at  every  movement  of  the  lips,  tongue,  and  soft  palate,  or 
when  hot  and  cold  liquids  or  irritating  solids  are  introduced  into  the 
mouth.  Taste  is  much  perverted,  or  is  entirely  wanting.  The  secre- 
tion poured  out  in  the  mouth  excites  a  subjective  taste  of  foulness,  and 
this  is  represented,  objectively,  by  an  odor  of  putrefaction,  especially 
when  there  are  carious  teeth. 

The  characteristic  of  the  aphthous  form  of  stomatitis  is  a  fibrinous 
exudation  occurring  first  in  the  follicles.  The  exudation  has  a  gray- 
ish or  yellowish-white  tint,  round  or  oval  in  shape,  and  varying  in  size 
from  the  head  of  a  pin  to  a  bean.  Subsequently,  additions  laterally  of 
fibrin  bring  the  isolated  deposits  in  contact,  and  thus  larger  patches 
are  formed.  The  exudation  softens  in  two  or  three  days,  the  mucous 
membrane  disintegrates,  and  small  ulcers  are  formed,  which  cicatrize 
in  a  week  or  two.  As  a  similar  process  takes  place  in  the  skin,  in 
variola,  the  same  terms  are  used  to  describe  the  variations  in  the  aph- 
thous patches  ;  thus  they  are  said  to  be  discrete,  coherent,  confluent, 
etc.  In  infancy  the  aphthous  exudation  is  arranged  somewhat  sym- 
metrically, on  the  vail  of  the  palate,  and  at  the  junction  of  the  vail 
with  the  bony  vault ;  in  adults,  the  exudation  occurring  in  the  follicles 
assumes  a  vesicular  and  pustular  character,  and  attacks  the  lips,  the 
cheeks,  and  the  point  of  the  tongue. 

Considerable  suffering  attends  aphthous  stomatitis ;  the  mouth  is 
dry  with  the  initial  hyperaemia  ;  but,  in  a  short  time,  a  transparent 
and  viscid  secretion  streams  from  the  mouth  ;  the  ulcers,  painful  at  all 
times,  are  exquisitely  so  when  acids,  sweets,  and  sapid  substances  are 
ingested,  and  by  the  mere  movements  of  the  jaws  in  mastication.  The 
breath  is  fetid ;  the  sublingual,  submaxillary,  and  parotid  glands 
become  swollen  and  sensitive  to  pressure.  The  system  at  large  sym- 
pathizes with  the  local  disturbance  ;  and,  in  children  especially,  there 
is  more  or  less  fever  ;  disturbances  of  the  digestive  organs  ensue  ;  the 
urine  becomes  scanty  and  high-colored.  It  occasionally  happens  that 
systemic  infection  takes  place,  with  all  the  evidences  of  the  most  pro- 
found adynamia — the  so-called  typhoid  state.  Gangrene  of  the  mu- 
cous membrane  may  then  set  in,  or,  commencing  in  the  mouth,  may 
induce  an  adynamic  state.  More  frequently,  aphthae  occur  in  the 
mouth  as  a  complication  in  typhoid  or  puerperal  fever,  when  gangrene 
of  the  mucous  membrane  may  follow. 


STOMATITIS.  3 

Muguet  is  a  term  applied  by  the  French  to  designate  a  form  of  exu- 
dative stomatitis,  the  special  characteristic  of  which  is  the  occurrence 
of  minute  parasitic  organisms.  The  local  morbid  process  is  the  same 
as  in  the  other  forms  of  stomatitis  :  hypersemia,  arrest  of,  followed  by 
greatly  increased  secretion  ;  production  of  new  cells  and  easting  off  of 
the  epithelium,  but  without  exudation  of  fibrin.  The  bviccal  secre- 
tion is  usually  acid,  a  condition  which  favors  the  growth  of  parasitic 
organisms.  Atmospheric  germs  are  deposited,  and  a  process  of  acid 
fermentation  goes  on  with  a  correlative  growth  of  microscopic  organ- 
isms. Whitish  masses,  looking  like  curds,  are  to  be  seen  on  the  pal- 
ate, cheeks,  tongue,  and  lips.  These  masses  may  remain  separate  and 
discrete,  or  enlarge,  cohere,  and  cover  the  whole  mucous  surface. 
They  may  also  extend  into  the  air-passages,  but  more  frequently  into 
and  through  the  intestinal  canal.  The  extension  into  the  latter  organs 
is  not  by  growth  along  contiguous  surfaces,  but  by  deglutition.  In 
the  fauces  these  curd-like  masses  interfere  with  deglutition,  in  the 
larynx  with  respiration. 

The  membrane-like  exudation  of  muguet  is  not  truly  a  membrane, 
but  is  a  collection  of  epithelial  and  mucous  corpuscles  matted  to  a 
mass  by  the  vegetation  of  oidium  albicans.  The  systemic  disturbance 
produced  by  it  depends  on  the  extent  of  the  patches  :  if  small  in  size 
and  discrete,  there  may  be  no  fever  and  only  restlessness  due  to  the 
soreness  of  the  mouth  ;  if  confluent,  there  may  be  considerable  fever. 
When  patches  develop  in  the  intestinal  canal  after  the  vegetations 
are  swallowed,  very  decided  gastro-intestinal  symptoms  may  be  pro- 
duced. There  will  be  more  or  less  diarrhoea,  or  the  stomach  may  be- 
come excessively  irritable,  food  being  rejected  as  soon  as  swallowed. 
The  suspension  of  or  serious  interruption  in  the  process  of  alimenta- 
tion causes  an  extreme  degree  of  angeraia  and  impairment  of  the  vital 
forces  with  cerebral  symptoms,  comprehended  under  the  term  hydren- 
cephaloid,  or  spurious  hydrocephalus.  These  cerebral  symptoms  are 
frequently  confounded  with  the  opposite  state — cerebral  congestion. 

Diagnosis, — The  ulcerative  form  of  stomatitis  is  to  be  distinguished 
from  syphilitic  mucous  patches.  The  distinction  rests  on  the  history, 
the  form  and  duration  of  the  patches,  and  the  presence  of  concomitant 
symptoms.  In  syphilis  the  ulcers  are  less  sharply  defined  and  contain 
ashy-gray  sloughs  closely  attached  ;  they  are  slow  to  heal,  and  appear 
and  disappear  ;  they  are  accompanied  by  other  syphilitic  lesions,  and 
preceded  by  a  characteristic  symptomatology. 

The  aphthous  form  of  stomatitis,  muguet,  may  be  confounded  with 
diphtheria.  The  differentiation  is  arrived  at  by  attention  to  the  fol- 
lowing points  :  In  diphtheria  the  exudation  usually  begins  as  a  delicate 
pellicle  on  the  tonsils  or  vail  of  the  palate  ;  in  muguet  as  a  curd-like  or 
pultaceous  mass,  on  the  lips,  gums,  or  cheeks — the  former  extending 
forward,  the  latter  backward.     The  exudation  of  diphtheria  thickens 


4  DISEASES  OF  THE  DIGESTIVE  SYSTEM.. 

and  widens  as  it  develops,  and  extends  into  the  Eustachian  tube, 
nares,  larynx,  and  to  wounded  surfaces  ;  that  of  muguet  is  rarely  co- 
herent, and  extends  into  the  fauces  and  oesophagus.  The  exudation  of 
muguet  is  made  up  of  cast-off  epithelium,  mucous  corpuscles,  and  the 
vegetation  of  oidium  albicans  ;  that  of  diphtheria,  of  a  true  fibrinous 
material  within  and  upon  the  epithelium,  and  an  immense  quantity  of 
bacteria,  which  also  extend  into  the  neighboring  vessels  and  lymphat- 
ics. The  odor,  the  swelling  of  the  cervical  lymphatics,  the  general 
systemic  infection,  and  the  profound  adynamia,  together  with  the  pe- 
culiar sequelae  of  diphtheria,  separate  this  malady  readily  from  aph- 
thous stomatitis. 

Treatment.— Attention  to  diet  is  of  the  first  importance.  Acid 
substances,  sweets,  and  condiments,  excite  smarting  and  distress  in  the 
process  of  mastication.  In  adults  ulcerative  stomatitis  is  often  due  to 
errors  of  diet,  and  such  subjects  soon  learn  that  acid  fruits  and  vegeta- 
bles, and  those  capable  of  acid  indigestion  in  the  stomach,  will  produce 
a  plentiful  crop  of  painful  ulcers  in  the  mouth.  Obviously,  in  such 
cases,  the  offending  articles  should  be  omitted  from  the  diet.  The 
starchy  and  saccharine  substances,  owing  to  their  facility  for  undergo- 
ing the  acid  fermentation,  may  be  equally  objectionable.  In  infants, 
to  avoid  the  evil  effects  of  acid  indigestion,  some  sodic  bicarbonate,  or 
lime-water,  is  added  to  the  milk.  In  ulcerative  stomatitis,  local  appli- 
cations are  highly  serviceable.  The  surface  of  each  ulcer  should  be 
cleansed,  and  a  little  pure  carbolic  acid  applied.  This  produces  a 
little  momentary  smarting,  but  great  relief  follows.  A  crystal  of  sul- 
phate of  copper,  or  nitrate-of -silver  stick,  may  be  used  to  touch  the 
surface  of  the  ulcers — to  set  up  a  new  action  in  the  diseased  part.  If 
the  local  disease  be  due  to  gastric  disorder,  besides  regulation  of  the 
diet,  remedies  to  allay  gastric  irritability  are  necessary  :  for  example, 
bismuth,  oxide  of  silver,  Fowler's  solution  of  arsenic,  hydrocyanic 
acid,  etc.  In  some  cases  remarkably  good  results  follow  the  admin- 
istration of  potassium  chlorate  in  large  doses — for  adults  fifteen  grains 
every  four  hours,  and  for  children  proportionally.  In  aphthous  stoma- 
titis the  same  principles  of  treatment  obtain  ;  but  some  attention  must 
be  given  to  the  peculiar  local  conditions.  As  the  extension  of  the 
patches  is  determined,  to  a  large  extent,  by  the  growth  of  the  oidium 
albicans,  remedies  destructive  of  minute  organisms  ought  to  be  em- 
ployed— as  salicylic  acid,  dissolved  by  aid  of  sodium  biborate  ;  quinia 
sulphate,  in  solutions  of  varying  strength  according  to  the  age  of  the 
subject;  carbolic  and  boracic  acid  solutions,  etc.  The  internal  admin- 
istration of  quinia  and  salicylic  acid,  to  arrest  the  spread  of  the  vegeta- 
tions swallowed,  is  highly  important.  A  combination  of  bismuth  and 
carbolic  acid  is  very  effective  to  relieve  the  extreme  imtability  of  the 
stomach.  Potassium  chlorate  is  equally  effective  in  this  as  in  the 
ulcerative  form.     To  be  successful,  it  is  necessary  to  administer  large 


•  GLOSSITIS.  5 

doses.  Mercurials  should  never  be  given  in  any  form,  for  the  destruc- 
tive ulcerations  and  the  gangrene,  which  now  and  then  occur,  will  be 
attributed  to  their  action. 

Mercurial  stomatitis  will  require  the  same  general  plan  of  treat- 
ment as  the  other  forms  of  the  disease,  with  the  exception  that  elimi- 
nation of  the  poison  must  be  promoted  by  the  administration  of  the 
iodide  of  potassium. 

GLOSSITIS. 

Definition. — Glossitis  is  a  term  signifying  inflammation  of  the 
tongue.  It  may  occur  in  the  mucous  membrane,  when  it  is  designated 
supei-ficial,  or  in  the  body  of  the  organ,  when  it  is  styled  deep-seated 
or  profound.  The  two  differ  as  widely  as  distinct  diseases  in  respect 
to  external  characters  and  gravity. 

Causes  and  Morbid  Anatomy. — The  superficial  variety  may  be  due 
to  traumatism — as  the  contact  of  hot  liquids,  steam,  and  other  local 
injuries.  It  may  constitute  a  part  of  a  morbid  process  involving  the 
•mucous  membrane  of  the  mouth.  The  deep-seated  variety  may  arise 
under  similar  conditions,  but  is  more  frequently  a  secondary  malady 
occurring  in  the  course  of  certain  infectious  diseases — as  erysipelas, 
typhoid,  pyaemia,  acute  rheumatism,  variola,  etc. 

The  anatomical  alterations  occurring  in  superficial  glossitis  consist 
in  swelling  and  redness,  with  desquamation  of  the  epithelium  of  the 
mucous  membrane.  This  change  is  found  on  the  borders  and  on  the 
dorsal  face  of  the  tongue,  giving  to  these  parts  a  red  and  raw  appear- 
ance. Another  variety  of  glossitis,  entitled  the  papilliform,  is  limited 
to  the  large  basal  papillae  of  the  tongue,  which  are  much  swollen  in 
consequence  of  a  hyperaemia  of  these  bodies  and  an  accumulation  of 
their  contents.  This  form  of  glossitis  is  usually  caused  by  the  irrita- 
tion of  tobacco-smoke,  or  is  syphilitic  in  origin. 

In  superficial  glossitis  the  taste  is  impaired  or  lost,  and  considerable 
pain  is  experienced  when  sapid  substances,  sweets,  and  acids  are  taken 
in  the  mouth.  The  flow  of  saliva  is  increased,  especially  on  the  occur- 
rence of  pain  and  smarting  from  the  mastication  of  sapid  substances. 
When  the  papillae  are  involved  alone,  there  will  be  present  heat  and 
smarting  in  the  act  of  mastication  and  deglutition,  especially  when 
the  substances  ingested  are  of  a  sapid  character,  or  are  too  hot. 

In  the  deep-seated  form  of  glossitis,  the  whole  tongue  is  usually 
involved.  The  mucous  membrane  is  swollen,  deeply  injected,  soft- 
ened, and  disintegrated,  deprived  of  its  epithelium,  and  detached  by  a 
fibrinous  exudation.  The  muscular  elements  are  separated  by  an  in- 
terstitial exudation  ;  they  soften,  disintegrate,  and  the  striae  sometimes 
disappear  in  a  species  of  granular  degeneration.  The  interstitial  con- 
nective tissue  is  also  involved,  and  hyperplasia  may  take  place,  lead- 
ing to  induration,  usually  in  patches,  but  the  cellular  elements  may 


6  DISEASES   OF   THE   DIGESTIVE   SYSTEM.   • 

undergo  multiplication,  and,  with  the  migrated  white  corpuscles,  form 
centers  or  tracts  of  suppuration.  In  favorable  cases  resolution  may 
occur,  and  the  healthy  state  be  restored.  As  very  frequently  the 
whole  tongue  is  involved,  considerable  swelling  may  ensue  and  life 
may  be  put  in  imminent  jeopardy  in  a  few  hours.  There  is  a  chronic 
form  of  glossitis,  interstitial  in  its  seat  and  chronic  in  its  character, 
which  consists  in  a  hyperplasia  of  the  connective  tissue,  and  conse- 
quent encroachment  on  the  muscular,  which  may  suffer  'atrophic 
changes  and  disappear. 

When  an  inflammation  involves  the  whole  tongue,  the  organ  may 
enlarge  enormously,  become  too  large,  indeed,  for  the  mouth,  and  pro- 
trude, the  teeth  marking  deep  indentations.  Similar  swelling  occurring 
posteriorly,  the  enlarged  organ  presses  painfully  against  the  hard  pal- 
ate, pushes  the  soft  palate  into  the  fauces,  and  the  epiglottis  against  the 
larynx,  thus  causing  gi-eat  difficulty  in,  or  preventing  entirely,  masti- 
cation and  deglutition.  The  voice  is  at  first  muf&ed  and  indistinct,  but 
subsequently  is  suppressed.  Very  great  pain  is  experienced  ;  a  tough 
and  rather  acrid  saliva  flows  from  the  mouth  incessantly  ;  the  lymphat-- 
ics  of  the  neck  are  swollen,  often  immensely  so,  and  tender  to  the 
touch,  and  the  face  is  puffy  and  cyanosed,  partly  in  consequence  of  the 
swelling  of  the  cervical  glands  preventing  the  return  of  blood  through 
the  jugulars,  and  partly  because  the  swollen  tongue  interferes  with  the 
entrance  of  air  to  the  larynx.  So  rapid  is  the  progress  of  the  swelling 
that,  in  twenty-four  to  thirty-six  hours,  death  may  occur  from  suffoca- 
tion, or  a  gradually  increasing  stupor  announce  the  onset  of  carbonic- 
acid  poisoning.  A  condition  of  imminent  danger  may  suddenly  cease, 
and  comparative  comfort  be  restored  by  the  discharge  of  pus,  conva- 
lescence soon  setting  in.  When  resolution  occurs,  the  swelling  gradu- 
ally subsides  from  the  maximum,  the  general  state  improves  corre- 
spondingly, and  health  is  ultimately  restored  in  its  entirety.  Rarely 
does  gangrene  ensue,  with  sloughing  and  subsequently  contraction  and 
impaired  mobility  of  the  tongue. 

During  the  existence  of  the  severe  local  symptoms,  especially  when 
they  occur  in  the  course  of  the  infectious  maladies,  the  general  state 
of  the  patient  indicates  the  gravity  of  the  disorder.  The  fever  rises 
and  is  intense,  the  restlessness  and  anxiety  are  great,  or  there  may 
be  delirium  of  the  low,  muttering  kind  when  carbonic-acid  poisoning 
comes  on.  Chills  and  high  fever,  the  temperature  rising  to  104°,  105°, 
or  106°  Fahr.,  and  sweats,  will  indicate  the  occurrence  of  suppuration. 
Increased  difficulty  of  breathing  may  be  due  to  an  extension  of  the 
suppuration  downward,  the  matter  dissecting  from  the  base  of  the 
tongue  under  the  aryteno-epiglottidean  folds. 

Course  and  Duration. — In  the  most  acute  cases  life  may  be  put 
in  jeopardy  by  the  swelling  which  prevents  the  access  of  air,  in  so 
short  a  time  as  twenty-four  hours.     The  occurrence  of  glossitis  in  the 


GAXGREXE   OF   TEE   MOUTH.  7 

course  of  an  infectious  malady,  which  has  ah-eady  taxed  the  powers  of 
life  to  the  utmost,  will  soon  determine  a  fatal  result.  Sudden  death 
may  ensue  from  oedema  of  the  glottis,  from  rupture  of  an  abscess  into 
important  parts,  or  from  paralysis  of  the  heart.  The  disease  may 
continue  several  weeks,  resolution  slowly  taking  place  ;  or,  an  abscess 
discharging  favorably,  speedy  recovery  will  ensue  ;  or  more  or  less 
sloughing  and  loss  of  substance  may  occur,  a  tedious  convalescence 
follow,  and  the  tongue  remain  impaired  in  its  functions. 

Diagnosis. — Glossitis  can  hardly  be  confounded  with  any  other 
affection.  Gumma  of  the  tongue  may  cause  sufficient  swelling  to  ap- 
pear like  the  first  stage  of  glossitis,  but  the  previous  history  and  the 
subsequent  course  of  the  latter  will  leave  no  room  for  doubt. 

Treatment. — The  superficial  form  of  glossitis  requires  the  same 
remedies  as  stomatitis,  or  it  may  be  safely  permitted  to  pursue  its 
natural  course,  a  suitable  regimen  being  enforced.  The  deep-seated 
form  requires  more  energetic  handling.  When  there  is  much  sthenic 
reaction,  the  subject  being  vigorous,  leeches  should  be  applied  under 
the  angles  of  the  jaws,  or  free  scarifications  of  the  tongue  should  be 
practiced.  Water,  as  hot  as  can  be  borne,  should  be  held  in  the  mouth 
as  long  and  as  frequently  as  possible  ;  or  ice  may  be  as  freely  used,  if 
grateful  or  more  beneficial  to  the  patient.  Deep  incisions  may  be 
necessary,  if  swelling  threatens  the  life  by  asphyxia,  or  to  evacuate 
matter.  Tracheotomy  may  be  required  in  an  extreme  case.  If  swal- 
lowing be  prevented  by  the  swelling,  a  flexible  tube  can  be  passed  into 
the  oesophagus  through  the  nares,  and  nutritive  liquids  be  thus  con- 
veyed into  the  stomach.  Support  by  suitable  aliment  is  required  from 
the  beginning,  and  the  use  of  alcoholic  stimulants  must  be  resorted  to 
as  soon  as  the  powers  of  life  flag.  At  the  beginning,  if  there  be  much 
reaction,  the  arterial  sedatives — aconite,  digitalis,  veratrum  viride — 
may  be  employed  ;  but  usually,  quinia  is  more  efficient  as  an  apyretic, 
and  to  check  the  formation  of  pus.  At  the  outset,  fifteen  to  twenty 
grains  of  quinia  and  half  a  grain  of  morphia  should  be  given  to  an 
adult,  and  subsequently  from  three  to  five  grains  of  quinia  and  one 
eighth  of  morphia,  every  four  hours.  If  swallowing  become  difficult, 
the  remedies  can  be  administered  in  solution  by  enema,  the  morphia 
being  suspended  if  there  be  any  indications  of  stupor  from  carbonic- 
acid  poisoning. 

GANGRENE  OF  THE  MOUTH— NOMA. 

Causes. — Gangrene  is  a  result  in  some  cases  of  stomatitis  ;  but 
these  are  not,  properly  speaking,  cases  of  noma,  which  is  a  special  dis- 
ease and  occurs  as  an  independent  affection.  It  is  a  disease  of  early 
life — from  three  to  five — and  attacks  the  child  of  squalid  poverty,  or 
those  living  under  the  most  unfavorable  hygienic  conditions.     It  is 


8  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

sometimes  an  accident  of  the  incautious  use  of  mercurials  in  unhealthy- 
subjects. 

Morbid  Anatomy  and  Symptoms. — The  inner  face  of  the  cheeks, 
more  usually  of  the  left  side,  is  the  favorite  site  of  the  gangrenous 
process.  At  first  a  deep-violet  or  purple  spot  appears,  surmounted  by 
a  vesicle  full  of  bloody  serum.  Softening  and  destruction  of  the  tis- 
sues take  place,  producing  a  quantity  of  sanies  and  detritus.  Large  exca- 
vations are  thus  formed,  which  widen  as  the  destruction  proceeds.  A 
horrid  stench  is  emitted  from  the  decomposing  mass.  The  jaws  are 
eroded,  the  teeth  loosened,  and  the  lips  invaded.  Thromboses  close 
the  veins,  but  the  arteries  "remain  permeable  ;  the  nerves  are  stained 
black,  but  are  not  otherwise  altered  in  structure.  If  a  cure  is  effected, 
very  great  deformities  may  result  in  the  process  of  cicatrization,  and 
the  functions  of  the  parts  be  seriously  impaired. 

Usually  this  disease  begins  silently  and  is  painless,  and  hence 
escapes  detection  until  the  appearance  of  a  grayish-black  mass  attracts 
attention  to  the  mouth.  When  fairly  inaugurated,  the  disease  extends 
so  rapidly  that  distinctive  symptoms  are  produced.  A  pronounced  odor 
of  animal  decomposition  is  exhaled  with  the  breath  ;  the  lips  and  cheeks 
become  swollen  and  cedematous  ;  the  sublingual  and  submaxillary 
glands  enlarge  ;  sanies  and  bloody  saliva,  mixed  with  the  gangrenous 
and  decomposing  materials  cast  off  from  the  sloughing  ulcer  within,  are 
constantly  flowing  from  the  mouth.  Marbling  of  the  dirty,  wax-colored 
skin  with  purplish,  vein-like  lines,  and  a  central  dark  spot  of  commenc- 
ing decomposition,  indicate  the  outward  extension  of  the  gangrene  to 
the  cheek. 

As  already  indicated,  during  the  first  few  days  of  the  disease  only 
local  symptoms  are  present  ;  but  then  auto-infection  ensues  by  reason 
of  the  absorption  of  the  gangrenous  materials,  and  an  adynamic  state 
is  produced.  Then  the  appetite  is  lost,  nausea  and  vomiting  occur, 
and  a  fetid  diarrhoea  supervenes.  The  strength  fails  rapidly,  the  pulse 
becomes  small  and  weak,  and  low-muttering  or  merely  nocturnal  de- 
lirium comes  on. 

Conrse,  Duration,  and  Termination.— The  course  and  duration  of 
the  malady  vary  with  the  age,  the  vigor  of  constitution,  and  the  hy- 
giene. The  gangrenous  eschar  on  the  cheek  usually  forms  within  the 
first  week,  and  death  may  occur  by  exhaustion  at  the  end  of  the  second 
week  ;  or  the  patient  may  be  cut  off  by  an  intercurrent  malady,  nota- 
bly pneumonia,  at  an  earlier  period.  Pursuing  its  ordinary  course, 
without  complications,  death  may  result  from  septicaemia  in  two  weeks. 
When  recovery  takes  place,  the  convalescence  will  be  rapid  or  tedious, 
according  to  the  amount  of  tissue  to  be  repaired,  and,  even  after  the 
arrest  of  the  gangrene,  the  powers  of  life  may  be  exhausted  by  the 
extensive  and  protracted  suppuration.  The  mortality  is  great,  and 
ranges  from  sixty  to  seventy  per  cent. 


PEARYNGITIS.  9 

Diagnosis. — Noma  is  to  be  distinguished  from  malignant  ulcer,  and 
from  ulcerous  stomatitis.  Malignant  ulcer  begins  on  the  lip  ;  noma 
on  the  mucous  membrane  within.  The  former  is  an  ulcer  covered 
with  an  ash-gray  slough  ;  the  latter  is  a  mass  of  blackish,  gangrenous, 
decomposing  tissues.  The  ulcero-membranous  stomatitis  consists  of  a 
number  of  small,  round  ulcers,  at  various  points,  that  do  not  become 
gangrenous,  and  heal  readily  on  appropriate  treatment. 

Treatment. — Support  to  the  powers  of  life  is  the  main  point,  and 
this  includes  not  only  aliment  but  air-space.  Alcoholic  stimulants 
must  be  used  early  and  freely.  Quinine  in  full  doses,  and  opium  cau- 
tiously, should  be  given  with  the  view  to  arrest  the  spread  of  the  gan- 
grene, and  to  prevent  septicaemic  infection.  If  administered  at  an 
early  period,  belladonna  seems  to  possess  the  power  to  prevent  the 
spread  of  the  gangrene.  It  is  very  important  to  destroy  the  first 
sloughing  tissue  by  active  caustics,  as  Vienna  paste,  chromic  acid,  zinc 
chloride,  muriatic  acid,  etc.  The  caustic  must  be  so  applied  as  to 
destroy  a  small  extent  of  surrounding  healthy  tissue. 


CATARRHAL   INFLAMMATION  OF   THE   NASO-PHARYNGEAL 
MUCOUS   MEMBRANE. 

Definition. — The  upper  pharynx,  into  which  the  posterior  nares 
enter,  is  the  seat  of  this  inflammation.     It  may  be  acute  or  chronic. 

Causes. — Inflammation  of  the  naso-pharyngeal  space  is  usually  a 
part  of  an  inflammation  involving  the  posterior  nares  and  the  lower 
pharynx.  The  most  prolific  cause  is  taking  cold.  Next  to  this  is  the 
use  of  cigarettes,  especially  if  the  smoke  is  inhaled  and  ejected  by 
the  nares  ;  and  then  comes  alcoholic  excess,  but  little  less  important. 
Diphtheria,  the  eruptive  fevers,  and  inflammatory  aifections  of  the 
air-passages,  are  accompanied  by  this  affection. 

Pathological  Anatomy. — An  intense  hyperaemia — a  vivid  redness — 
is  the  first  change,  but  in  chronic  cases  the  color  of  the  membrane  is 
reddish-brown.  As  a  result  of  the  congestion,  haemorrhagic  extrava- 
sations may  occur.  The  mucous  membrane  is  swollen,  infiltrated,  and 
projecting  from  the  general  surface  are  numerous  enlarged  follicles. 
The  increase  in  size  of  the  follicles  is  due  largely  to  the  increase  and 
accumulation  of  their  cellular  contents.  The  pharyngeal  tonsils  are 
enlarged  from  the  swelling  of  the  mucous  membrane,  and  the  orifices  of 
the  Eustachian  tubes  are  changed  in  form  by  the  same  cause,  or  even 
obstructed.  A  quantity  of  glairy,  tenacious  mucus  is  poured  out,  and 
coats  the  surface  of  the  membrane.  In  chronic  qases,  the  mucous 
membrane  is  much  altered  by  the  enlarged  and  tortuous  veins,  by 
haemorrhagic  extravasation,  and  by  the  hypertrophic  enlargements 
of  the  follicles.  In  very  old  cases  the  mucous  membrane  undergoes 
atrophy.     There  is  also  increased  secretion  ;  the  mucus  is  mixed  with 


10  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

pus,  and  not  unfrequently  with  blood,  and  a  thick  string  of  muco-pus 
can  often  be  seen  projecting  down  into  the  lower  pharynx,  behind  the 
soft  palate.  Erosions  of  the  epithelium  also  take  place,  and  super- 
ficial ulcers  form. 

Symptoms. — There  is  at  first,  in  acute  cases,  an  unpleasant,  stuffy, 
and  dry  feeling  in  the  naso-pharyngeaL  space,  followed  in  a  short  time 
by  increase  of  secretion  falling  into  the  pharynx  or  discharging  by  the 
anterior  nares.  There  may  be  some  headache  and  pains  in  the  upper 
jaws.  Breathing  through  the  nose  is  difiicult.  The  voice  is  thick  and 
nasal.  The  symptoms  of  an  acute  attack  subside  in  a  few  days,  the 
secretion  changing  to  a  yellow  muco-pus  from  the  transparent,  glairy 
mucus  which  first  appeared,  breathing  through  the  nose  becoming 
natural,  and  the  voice  assuming  its  normal  tone. 

In  the  chronic  form,  the  symptoms  succeed  to  the  acute  or  develop 
slowly  from  the  causes  continuously  acting.  The  posterior  nares  are 
more  or  less  obstructed,  constantly  to  a  slight  extent  by  the  swelling 
of  the  mucous  membrane,  and  occasionally  \erf  much  by  accumula- 
tion of  mucus.  Breathing  through  the  nose  may  be  sometimes  pre- 
vented. The  voice  is  more  or  less  thick  and  nasal.  Pain  in  the  ear 
may  be  felt,  and  dullness  of  hearing  is  a  common  symptom  from  ob- 
struction of  the  Eustachian  tube.  The  mucus,  hanging  down  into  the 
lower  pharynx,  excites  frequent  attempts  to  swallow,  and  causes  a 
feeling  of  the  presence  of  a  foreign  body.  A  disagreeable  habit  of 
hawking  is  induced  in  this  way.  In  very  chronic  cases  with  atrophy 
of  the  mucous  membrane,  secretion  ceases,  and  the  membrane  has  a 
dry  and  glazed  appearance. 

Course,  Duration,  and  Termination. — The  course  of  the  acute  form 
is  short,  and  the  termination  is  in  health,  or  in  the  chronic  form.  The 
chronic  form  is  very  slow,  and  is  usually  regarded  of  importance  only 
when  a  thick  band  of  mucus  hangs  into  the  lower  pharjmx,  and  ex- 
cites efforts  to  clear  the  throat.  As  a  not  infrequent  cause  of  deafness 
it  comes  under  the  observation  of  the  aural  surgeon.  Although  cu- 
rable under  appropriate  management,  the  treatment  is  very  protracted. 
As  success  in  the  treatment  requires  abstention  from  the  two  preva- 
lent habits  of  smoking  and  drinking  spirituous  liquors,  success  will 
depend  on  the  conduct  of  the  patient  very  largely.  Left  to  itself,  the 
duration  is  indefinite. 

Treatment. — The  first  step  in  the  treatment  is  to  free  the  mucous 
membrane  from  the  viscid  discharge.  This  is  best  accomplished  by 
washing  out  the  cavity  with  the  post-nasal  syringe,  employing  a  solu- 
tion of  common  salt  or  carbonate  of  sodium  (3  j  —  |  iv).  The  syringe 
is  passed  behind  the  vail  of  the  palate,  the  fluid  discharged,  when,  the 
patient  leaning  forward,  it  escapes  into  a  vessel  placed  to  receive  it. 
So  much  damage  to  the  ear  has  resulted  from  the  incautious  use  of  the 
nasal  douche,  that  the  author  advises  the  curved  post-nasal  syringe  for 


CATARRHAL   INFLAMMATION   OF   THE   LOWER  PHARYNX.  H 

the  purpose  just  indicated.  Keeping  the  mucous  membrane  free  from 
the  unhealthy  mucus  is  an  important  point.  The  agents  used  to  bring 
about  a  cure  of  the  chronic  inflammation  are  very  numerous.  Strong 
applications  are  injurious.  Those  most  frequently  employed  are  the 
salts  of  zinc,  copper,  and  silver.  One  grain  of  sulphate  of  zinc  to  four 
ounces  of  water  is  strong  enough.  The  author  finds  that  dry  appli- 
cations— powders  used  by  the  method  of  insufflation — are  greatly  supe- 
rior in  efficacy  to  all  other  modes  of  treatment.  A  mixture  of  tannin 
and  iodoform  is  the  best  formula  (  3  j  of  tannin  —  gr,  x  of  iodoform). 
A  minute  quantity  of  this  is  put  into  the  chamber  of  the  insufflator 
and  blown  into  the  naso-pharyngeal  space.  This  instrument  must 
have  a  long  tube,  and  be  suitably  curved,  so  that  it  can  be  passed  be- 
hind the  palate.  The  salts  of  zinc,  copper,  and  silver,  iodoform,  calo- 
mel, bismuth,  may  be  used  in  the  same  way.  Next  to  tannin  and 
iodoform,  insufflations  of  bismuth  are  most  useful.  When  the  former 
produce  much  irritation,  the  author  uses  bismuth  in  the  interim  of  the 
applications. 

CATARRHAL   INFLAMMATION   OF   THE    LOWER   PHARYNX. 

Pathogeny  and  Symptoms. — This  may  be  acute  or  chronic.  Both 
forms  arise  under  precisely  the  same  conditions  as  the  corresponding 
maladies  of  the  naso-pharyngeal  space.  The  changes  in  the  acute  form 
consist  of  redness,  swelling  of  the  mucous  membrane,  enlargement  of 
the  follicles  from  accumulation  of  their  contents,  and  increased  secre- 
tion, coming  on  after  a  very  brief  dry  stage.  These  anatomical  condi- 
tions are  not  limited  to  the  pharynx.  In  the  chronic  form,  the  changes 
are  more  decided.  The  mucous  membrane  is  of  a  deep  reddish-brown, 
or,  in  very  old  cases,  grayish.  The  vessels  of  the  mucous  membrane 
are  enlarged  and  tortuous.  The  follicles  are  enlarged  and  prominent, 
and  have  a  grayish  or  reddish-gray  color  ;  there  may  be  considerable 
development  in  places  of  the  squamous  epithelium,  and  ulcers,  rather 
shallow  than  deep,  form  in  various  situations.  The  symptoms  are  by 
no  means  pronounced.  Dryness,  a  sense  of  heat  and  irritation,  a  feel- 
ing as  if  something  were  adherent  to  the  mucous  membi'ane,  much 
hawking  and  clearing  the  throat,  are  the  chief  sensations.  On  inspec- 
tion of  the  fauces  the  mucous  membrane  is  seen  to  be  of  a  deep,  red- 
dish-brown color,  thick,  coated  with  a  tenacious  mucus,  and  roughened 
by  enlarged  follicles.  In  very  old  cases  the  posterior  wall  of  the  phar- 
ynx is  smooth,  thin,  and  glazed,  and  has  adherent  to  it  dry  masses  of 
mucus,  colored  by  dust. 

Treatment. — The  principles  and  the  methods  of  practice  advised 
for  the  naso-pharyngeal  space  are  equally  applicable  here. 


12  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

RETRO-PHARYNGEAL  ABSCESS. 

Definition. — By  this  term  is  meant  an  accumulation  of  pus  in  the 
submucous  connective  tissue,  posterior  to  the  pharyngeal  wall.  An 
abscess  may  form  in  the  mucous  membrane  itself — this  is  entitled 
pharyngeal  abscess. 

Causes. — Diseases  of  the  cervical  vertebra,  of  the  atlas  and  axis, 
and  caries,  are  the  principal  causes.  Large  collections  are  formed  in 
the  same  situation,  from  suppuration  in  the  bronchial  glands,  and  in 
the  deep  cervical  lymphatics — the  pus  dissecting  up  under  the  mucous 
membrane,  and  pointing  in  the  pharynx.  Again,  an  abscess  may  be 
the  result  of  an  inflammation  of  the  loose  connective  tissue,  under  the 
pharyngeal  mucous  membrane,  a  disease  not  infrequent  in  children 
before  the  tenth  year. 

Symptoms. — The  abscess  produced  by  an  acute  inflammation  of  the 
connective  tissue  is  very  acute  in  its  course.  It  begins  with  chill,  high 
fever,  sleeplessness,  intense  restlessness,  and  in  very  young  children 
there  may  be  convulsions.  When  the  abscess  results  from  caries  of 
the  vertebrae,  its  march  is  slower,  and  the  symptoms  of  pharyngeal 
obstruction  are  the  first  to  call  attention  to  this  part.  Pain  in  moving 
the  head  is  felt,  and  hence  it  assumes  a  fixed  position,  the  cervical 
muscles  being  rigid.  Then  difliculty  of  swallowing  and  dyspnoea  come 
on.  If  digital  exploration  is  then  made  by  passing  the  index-finger 
gently  over  the  base  of  the  tongue,  a  hard,  brawny,  possibly  fluctuating 
swelling  may  be  detected  in  the  pharynx.  The  neck  will  also  be  much 
swollen  externally,  and  fluctuation  may  ultimately  be  felt  under  the 
angle  of  the  jaw.  Suppuration  is  often  announced  by  the  occurrence 
of  a  chill,  and  the  fever  will  then  assume  an  intermittent  or  remittent 
type,  and  profuse  sweats  will  occur.  The  abscess,  if  not  interfered  with 
by  art,  will  discharge  spontaneously  into  the  lower  pharynx,  or  exter- 
nally, or  form  fistulous  communication  with  the  cavity.  The  author  has 
seen  one  case  in  an  adult,  which  extended  from  the  basilar  process  to 
the  root  of  the  lungs.  When  spontaneous  opening  of  the  abscess  takes 
place,  suffocation  may  be  caused  by  escape  of  the  matter  into  the 
larynx.  Death  may  also  be  caused  by  the  size  of  the  collection,  the 
larynx  being  occluded,  or  by  secondary  disease  of  the  air-passages,  or 
by  thrombosis  of  the  transverse  sinus,  or  jugular  vein,  or  even  of  the 
carotid  artery. 

Course,  Duration,  and  Termination.— There  are  great  differences,  ac- 
cording to  the  origin  of  the  abscess,  in  the  course  pursued.  Those  due 
to  caries  of  the  vertebra  are  slow  in  development,  but  fatal  in  result. 
The  phlegmonous  abscess  is  acute,  pursues  its  course  in  from  five  to 
twenty  days  or  longer,  and  the  danger  is  determined  by  the  size  of  the 
collection,  and  the  direction  taken  by  the  pus  if  not  spontaneously 
evacuated.     If  not  large,  the  abscess  will  discharge  and  heal  without 


(ESOPHAGITIS.  13 

danger  to  life.     The  large  submucous  abscess  will  almost  always  prove 
fatal  by  exhaustion. 

Treatment. — Pus  should  be  evacuated  at  the  earliest  moment.  The 
powers  of  life  must  be  sustained  by  proper  aliment  and  the  free  use  of 
stimulants.  The  formation  and  spread  of  pus  must  be  limited  by  the 
administration  of  quinia,  as  far  as  such  a  result  is  possible. 


DISEASES   OE   THE   (ESOPHAGUS 


CATARRH  OF  THE   CESOPHAGUS.— CESOPHAGITIS. 

Causes. — Acute  oesophagitis  exists  only  as  a  part  of  a  morbid  pro- 
cess involving  the  mouth,  fauces,  and  stomach.  Typical  examples  are 
afforded  by  the  action  of  irritant  poisons  and  corrosive  substances. 
The  chronic  variety  is  produced  by  the  causes  which  give  rise  to  the 
chronic  stomatitis.  The  acute  and  chronic  forms  differ  so  little  that 
they  may  be  considered  together.  The  change  in  the  mucous  mem- 
brane consists  in  more  or  less  hypersemia,  especially  about  the  follicles ; 
at  first  an  arrest  of  secretion,  followed  by  an  abundant  pouring  out 
of  mucus,  which  in  the  chronic  form  is  always  in  excess.  Consider- 
able hypertrophic  thickening  of  the  mucous  membrane  occurs  in  the 
chronic  malady,  and  in  some  situations  takes  on  the  form  of  papillary 
or  polypoid-like  outgrowths.  Coincident  thickening  of  the  muscular 
layer  also  occurs.  Erosions  of  the  mucous  membrane,  at  first  super- 
ficial, are  produced  by  disintegration  and  separation  of  the  epithelium, 
and  ulcers  are  then  formed,  which  may  extend  to  the  deeper  layers. 
The  greatest  diameter  of  these  ulcers  is  parallel  to  the  long  axis  of 
the  tube.  Ulcers  also  result  from  the  impaction  of  foreign  bodies  ; 
from  corrosive  liquids  ;  from  tubercular  deposition,  etc.  The  catarrhal 
form  may  be  confined  to  the  follicles,  when  it  is  called  follicular 
oesophagitis.  The  follicles  are  swollen  and  prominent,  partly  in  con- 
sequence of  an  abnormal  accumulation  of  their  contents,  and  partly  in 
consequence  of  an  hypertrophy  and  contraction  of  the  adjacent  con- 
nective tissue.  The  diseased  follicles  appear  as  firm  nodules,  some- 
what conical  in  shape,  projecting  above  the  general  surface,  and  irreg- 
ularly distributed  along  the  tube.  A  fibrous  or  croupous  oesophagitis 
also  exists,  not  as  an  independent  affection,  but  consisting  of  an  exten- 
sion downward  of  an  exudation,  croupous  or  diphtheritic,  or  occurs  as 
a  complication  in  typhus,  scarlet  fever,  small-pox,  etc.     There  is,  also, 


14  DISEASES   OF  THE   DIGESTIVE   SYSTEM. 

a  phlegmonous  or  purulent  inflammation  of  the  oesophagus,  which 
comes  on  by  extension  of  purulent  infiltration  of  neighboring  parts,  as 
in  perichondritis  of  the  larynx,  by  the  action  of  corrosive  substances, 
by  lodgment  of  foreign  bodies,  etc. 

Symptoms. — In  either  acute  or  chronic  form,  oesophagitis  produces 
but  few  symptoms.  Pain  in  swallowing  is  usually  present  in  the  acute 
form,  and  may  be  developed  in  the  chronic  cases  by  the  ingestion  of 
hot  or  rough  foods.  Pain  may  be  caused  by  pressure  on  the  tube  from 
without,  and  by  the  passage  of  an  oesophageal  bougie — a  procedure  by 
which  we  may  designate  the  seat  of  ulceration,  or  lesser  kinds  of  irri- 
tation, even.  When  there  is  severe  local  disease  at  any  point,  as  an 
ulcer,  for  example,  food  swallowed  descends  to  that  point,  excites  a 
sensation  of  heat  and  pain,  and  is  then  regurgitated  by  a  sudden  reflex 
spasm  of  the  tube.  Sometimes  mucus  or  muco-purulent  matter  will 
be  found  adherent  to  the  particles  of  food.  Chronic  catarrh  is  espe- 
cially characterized  by  the  production  of  much  glairy  and  tenacious 
mucus,  which  rises  into  the  pharynx,  causing  the  sensation  of  the 
presence  of  a  foreign  body.  The  attempt  to  clear  the  throat  of  this 
often  excites  gagging.  These  symptoms  are,  not  unfrequently,  con- 
founded with  those  due  to  corresponding  diseases  of  the  throat,  espe- 
cially chronic  and  follicular  catarrh. 

Course  and  Duration. — Simple  acute  catarrh  terminates  in  a  few 
days.  When  produced  by  corrosive  liquids,  the  process  of  cicatriza- 
tion will  occupy  several  weeks,  and  subsequent  contractions  and  stric- 
tures may  so  interfere  with  nutrition  as  to  cause  death  by  marasmus 
after  many  months.  The  chronic,  and  especially  the  follicular,  variety 
may  continue  unchanged  for  years. 

Treatment. — The  management  of  the  various  forms  of  oesophagitis 
is  the  same  as  the  corresponding  affections  of  the  mucous  membrane  of 
the  mouth.  The  topical  applications  must  necessarily  be  restricted  to 
the  agent  swallowed. 

DYSPHAGIA. 

Dysphagia,  or  difficulty  of  swallowing,  is  a  symptom  of  disease, 
but  not  a  disease  itself.  It  is  frequently  hysterical,  when  it  is  accom- 
panied by  other  hysterical  manifestations,  as  the  globus  hystericus, 
laughing  and  crying,  etc.  It  may  be  hypochondriacal,  when  the  pa- 
tients present  the  deep  dejection,  the  indifference,  and  other  symptoms 
of  that  state.  It  may  be  due  to  stricture,  succeeding  to  injury  by 
steam,  corrosive  liquids,  injuries  of  various  kinds,  cicatricial  tissue, 
malignant  disease,  etc.  It  may  also  be  due  to  paralysis  of  the  palate, 
a  sequel  of  diphtheria.  It  will  be  more  appropriately  considered  when 
these  topics  are  discussed. 


STENOSIS   OF  THE   (ESOPHAGUS.  15 


STENOSIS   OF  THE   CESOPHAGUS. 

Causes. — The  term  stenosis  signifies  narrowing  of  the  oesophagus, 
produced  in  various  ways.  It  may  be  congenital  or  acquired  :  the  lat- 
ter only  will  be  considered  here.  As  regards  acquired  stenoses,  they 
may  be  produced  by  causes  acting  from  without,  by  compression  ; 
within,  by  obstruction.  As  respects  those  acting  from  without,  we 
find  the  lumen  of  the  oesophagus  narrowed  by  tumors,  the  enlarged 
thyroid,  aneurisms,  caseous  lymphatics,  etc.  Obstructions  from  the  in- 
terior are  caused  by  foreign  bodies  lodged,  which  usually  produce  acute 
symptoms,  but  sometimes  remain,  lodged  in  pockets  or  diverticula, 
for  months  or  years.  Parasitic  growths  gradually  developing  may 
cause  stenosis.  Fibroid  polypi,  club-shaped  or  lobulated,  slowly  ob- 
struct the  canal,  and  hence  cause  the  symptoms  of  obstruction  very 
slowly.  Strictures  are  formed  by  the  contraction  of  cicatrices,  or  by 
carcinoma.  Cancerous  stenoses  are  more  frequent  than  all  the  others 
combined.  Their  usual  seat  is  the  lower  third  of  the  canal,  and  they 
may  involve  the  whole  periphery  and  a  considerable  part  longitudi- 
nally. 

Symptoms. — Increasing  difficulty  in  the  passage  of  food,  which  the 
patient  recognizes  at  a  certain  point,  is  usually  the  first  symptom  ex- 
perienced. Swallowing  is  successful,  but  the  patient  feels  a  sense  of 
obstruction  below,  requiring  at  first  repeated  attempts  at  swallowing 
to  overcome  ;  then  repeated  sips  of  water,  with  more  swallowing  to 
dislodge  the  bolus  ;  and,  when  the  obstruction  reaches  a  certain  point, 
regurgitation  occurs,  not  in  consequence  of  an  inverted  peristalsis,  but 
the  mechanical  effect  of  partial  compression  of  a  tube  containing  liquid 
contents.  The  position  of  the  obstruction  is  pretty  accurately  indi- 
cated by  the  sensations  of  the  patient  and  by  the  time  when  regurgi- 
tation takes  place.  In  acute  stenosis — from  burns,  scalds,  and  corro- 
sives— and  in  chronic  carcinoma,  when  complete  obstruction  occurs, 
food  is  regurgitated  as  soon  as  swallowed.  The  physical  signs  of 
stenosis  are  important.  On  mspection  in  thin  persons,  the  movement 
of  the  bolus  may  be  seen  descending  to  the  point  of  stoppage  if  high 
enough  up,  or  the  return  movement  may  be  discerned.  Enlarged  lym- 
phatics may  be  visible  at  the  root  of  the  neck,  and  the  abdomen, 
especially  the  hypochondria,  may  be  flattened  and  retracted,  indicat- 
ing starvation.  On  auscultation  the  normal  oesophageal  sound  pro- 
duced by  the  passage  of  foods  may  be  heard  suddenly  arrested  at  the 
point  of  obstruction  and  passing  upward  on  regurgitation,  or  various 
adventitious  sounds  may  be  audible,  as  gurgling,  sucking,  spluttering, 
etc.,  at  the  point  of  narrowing.  An  important  symptom  is  spasm  of 
the  glottis,  produced  by  pressure  of  a  growth,  especially  cancerous,  on 
the  recurrent  laryngeal  nerve.  A  peculiar  cough,  sudden  paroxysms 
of  difficult  breathing,  and  a  toneless  voice,  are  thus  caused.     Difficulty 


16  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

of  breathing  may  also  be  due  to  pressure  on  the  trachea  simultaneously 
with  the  oesophageal  pressure.  The  most  tormenting  hunger  and  thirst 
arise  in  the  progress  of  the  case,  and  increase  with  the  increasing  dif- 
ficulty of  getting  aliment  in  the  stomach  ;  the  body  emaciates  to  an 
extraordinary  extent ;  the  mind  is  incessantly  occupied  with  thoughts 
of  savory  viands,  and,  in  the  delirium  with  which  the  scene  closes,  the 
hapless  patient  is  engaged  with  the  most  sumptuous  repasts. 

Diagnosis. — The  spasmodic  stenosis  of  the  hysterical  and  hypochon- 
driacal is  accompanied  by  the  usual  symptoms  of  these  states,  and  the 
condition  of  the  patient  as  to  nutrition  is  not  in  harmony  with  the 
gravity  of  the  local  phenomena.  Acute  stenosis  is  preceded  by  the 
history  of  injury  by  scalding  or  burning,  or  by  the  ingestion  of  corro- 
sive liquids.  The  question  of  cancer  is  to  be  considered  with  refer- 
ence to  the  age,  which  is,  almost  always  after  forty-five,  and  the  de- 
velopment of  the  disease  is  marked  by  a  gradually  increasing  difiiculty 
of  swallowing,  by  marasmus,  and  the  cancerous  cachexia.  External 
compression  may  be  produced  by  enlarged  lymphatics,  by  an  hypertro- 
phied  thyroid,  by  mediastinal  and  cervical  tumors;  but  these  can  easily 
be  differentiated  from  all  kinds  of  internal  obstruction.  An  aneurism 
of  the  arch  of  the  aorta,  by  compression  of  the  oesophagus  and  of  the 
recurrent  laryngeal  nerve,  will  cause  symptoms  not  unlike  those  due 
to  cancer  of  this  tube  ;  but  there  will  be  present»the  signs  of  aneurism. 
Diagnosis  will  in  all  cases  be  greatly  facilitated  by  the  oesophageal 
bougie  ;  but  this  instrument  must  be  used  with  caution  when  the  canal 
is  much  injured,  lest  perforation  be  produced  by  its  passage. 

Prognosis. — The  termination  is  fatal  in  a  large  proportion  of  cases 
of  stenosis  ;  but  excellent  results  may,  sometimes,  be  obtained  by  the 
patient  and  persistent  use  of  the  means  of  dilatation  in  cases  of  steno- 
sis by  cicatrices. 

Treatment. — So  far  as  medical  management  is  concerned,  it  is  de- 
termined by  the  causes  of  the  obstruction,  and  it  is  not  our  province  to 
discuss  surgical  expedients. 

DILATATIONS  OF  THE  OESOPHAGUS. 

Causes. — Dilatation,  or  ektasia,  is  a  uniform  enlargement  of  the 
oesophagus,  the  whole  cylinder  usually  being  involved.  A  diverticu- 
lum is  a  protrusion  from  the  walls  laterally,  forming  a  sac  of  greater 
or  less  extent.  Ektasia  may  be  caused  by  fatty  degeneration  of  the 
muscular  layer,  which  yields  in  the  act  of  contracting  on  the  bolus  as 
it  descends  to  the  stomach.  With  increasing  dilatation,  there  is  in- 
creasing weakness  of  the  muscular .  layer  and  consequent  dysphagia. 
Vomiting  and  regurgitation  presently  occur  ;  after  a  while  the  nutri- 
tion fails,  and  the  objective  symptoms  are  similar  to  those  of  stenosis, 
the  ultimate  result  being  equally  unfortunate.     Diverticula  may  be 


DILATATIONS  OF  THE  (ESOPHAGUS.  lY 

caused  by  the  lodgment  of  foreign  bodies  leading  to  the  formation  of 
pouch-like  protrusions.  Pressure  diverticula  are  usually  situated  at  or 
about  the  junction  of  the  pharynx  with  the  oesophagus,  and  in  the 
median  line,  posteriorly,  for  here  the  longitudinal  muscular  fibers  are 
wanting  and  the  pressure  is  greatest.  When  fully  formed,  they  are 
deep  pockets,  or  sacs,  of  varying  length,  and  may  be  several  inches 
deep.  The  first  step  in  their  formation  is  the  lodgment  of  a  foreign 
body  ;  then  yielding  of  the  muscular  layer  of  the  tube,  due  to  fatty 
degeneration  of  the  muscular  elements  ;  increasing  pressure  from  de- 
posits of  food  and  drink  ;  the  final  result  being  a  sac  extending  down- 
ward and  behind  the  oesophagus.  The  mechanical  effect  of  a  sac  in 
this  situation  is  to  push  the  tube  before  it  and  compress  it,  so  that  ulti- 
mately the  food  and  drink  drop  into  the  sac  instead  of  passing  into 
the  stomach,  thus  causing  the  symptoms  of  stenosis.  The  symptoms, 
however,  develop  more  slowly  than  in  even  the  most  chronic  cases  of 
stenosis.  Diverticula  occur  in  the  great  majority  of  instances  after 
forty,  whence  it  happens  that  they  are  often  confounded  with  cancer  ; 
there  is  no  cachexia,  and  the  symptoms  continue  for  years.  A  bulg- 
ing, variable  in  size,  may  often  be  observed  above  the  level  of  the  cri- 
coid cartilage  ;  this  marks  the  position  of  the  diverticulum  within. 
The  food  accumulating  here  may,  by  the  contraction  of  the  cervical 
muscles  or  by  the  fingers  of  the  patient,  be  dislodged  and  is  then 
regurgitated.  The  sound  enters  the  sac,  but  is  not  tightly  embraced 
by  it,  as  is  a  stricture,  and  moves  about  freely  in  the  cavity.  Traction 
diverticula  are  found  low  down,  opposite  the  bifurcation  of  the  trachea, 
and  are  caused  by  various  inflammatory  conditions  leading  to  adhesion 
with  the  oesophagus.  The  traction  thus  caused  induces  the  formation 
of  diverticula. 


DISEASES  OF  THE   STOMACH. 


FORMS  AND  VARIETIES. 

The  diseases  of  the  stomach  are  named  according  to  their  charac- 
ter and  anatomical  seat.  Inflammation  of  the  stomach  is  called  gas- 
tritis, and  may  occur  in  the  mucous  membrane,  or  in  the  submucous 
connective  tissue.  The  mucous  variety  is  known  as  gastric  catarrh, 
and  then  consists  of  two  forms — acute  and  chronic  ;  the  submucous 
variety  is  designated  phlegmonous  or  interstitial  gastritis,  and  may 
also  occur  in  two  forms — acute  and  chronic  ;  the  latter  is  sometimes 
2 


18  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

called  cirrhosis  of  the  stomach.  There  is  also  a  form  of  gastritis 
caused  by  the  ingestion  of  corrosive  and  irritant  poisons — toxic  gastri- 
tis. Under  the  term  embarras  gastrique  the  French  authors  describe 
a  light  foi"m  of  gastric  catarrh,  due  to  the  use  of  various  kinds  of  indi- 
gestible aliment.  Severe  cases  of  gastric  catarrh,  in  which,  in  addition 
to  the  ordinary  symptoms  of  indigestion,  there  is  present  fever,  lasting 
about  a  week,  have  been  called  gastric  fever.  Chronic  gastric  catarrh 
is  only  another  name  for  dyspepsia. 

ACUTE  GASTRITIS- 

Causes. — The  stomach  is  much  affected  by  atmospherical  changes. 
An  illustration  of  this  is  afforded  in  the  summer  and  autumnal  attacks 
of  bilious  and  gastric  fevers,  so  called,  induced  as  they  are  by  the  very 
considerable  vicissitudes  of  temperature,  the  hot  days  and  cool  nights 
of  the  autumn.  Gastric  catarrh  occurs  at  all  ages  after  infancy,  and 
is  more  frequent  in  men  than  in  women.  The  most  common  causes 
are  errors  of  diet,  insufficient  mastication  of  food,  swallowing  too  hot 
or  too  cold  liquids,  excessive  eating,  abuse  of  ices,  condiments,  and 
sauces,  etc.  ;  and  especially  of  alcoholic  drinks.  Various  external  influ- 
ences and  moral  causes  affect  the  digestive  functions,  as  occupation, 
exercise,  sedentary  habits,  grief,  etc. 

Pathological  Anatomy, — In  the  simplest  cases,  the  lesions  may  be 
so  slight  as  to  escape  detection  ;  in  mild  but  fully  developed  cases  the 
changes  are  about  as  follows  :  The  mucosa  is  the  seat  of  a  delicate  in- 
jection occurring  in  isolated  spots,  arborescent  or  generalized  to  the 
whole  membrane.  Usually  at  or  near  the  cardiac  orifice,  the  injection 
or  hyperaemia  is  most  pronounced.  The  mucous  membrane  may  be 
intensely  engorged,  and  covered  with  a  grayish,  semi-transparent,  and 
tenacious  mucus  (Orth,  page  287).  It  should  not  be  forgotten  that 
enormous  congestion  of  the  stomach  may  exist  in  cases  of  mitral  ob- 
struction and  regurgitation.  The  similarity  of  this  to  true  catarrhal 
states  is  rendered  the  more  confusing,  because  of  the  quantity  of  glairy 
and  tenacious  mucus  found  attached  to  the  mucous  membrane  so  firmly 
as  to  be  washed  off  with  difficulty  (Wilks  and  Moxon,  page  380).  The 
mucous  glands  are  prominent,  and  are  increased  in  size  above  the  nor- 
mal, in  consequence  of  the  overgrowth  of  their  contained  cells  and 
the  hypertrophy  of  the  adjacent  connective  tissue.  In  chronic  cases, 
the  glands  have  shrunk  (atrophy),  or  have  become  cystic,  in  some  situ- 
ations, because  of  the  pressure  produced  by  the  contracting  connec- 
tive tissue.  Sometimes  the  mucous  membrane  is  softened  and  easily 
stripped  off  ;  then  again,  it  is  indurated  and  much  thickened,  in  conse- 
quence of  interstitial  inflammation.  Much  confusion  has  arisen  in 
regard  to  the  term  "  mammillated,"  which  consists  in  the  formation 
of  numerous  small,  conical  eminences,  by  the  contraction  of  the  sub- 


ACUTE   GASTRITIS.  I9 

mucous  connective  tissue,  or  of  the  muscular  layer,  similar  to  cutis  an- 
serina.  This  appearance  can  not  be  regarded  as  morbid,  unless  asso- 
ciated with  other  anatomical  changes.  Ecchymoses  are  found,  and  also 
dark,  brownish  patches,  the  result  of  subsequent  changes  in  the  effused 
blood.  Erosions  also  occur  here  and  there  of  various  sizes,  but  not 
often  of  considerable  size,  and  just  about  them  the  mucous  membrane 
is  softened.  An  (Edematous  appearance  of  the  mucous  membrane  is 
caused  by  an  infiltration  by  serum  and  sero-albumen  of  the  submucous 
connective  tissue.  The  proper  secretion  of  the  gastric  glands  is  much 
affected  by  these  anatomical  alterations.  The  true  gastric  juice  is  no 
longer  secreted,  or  its  production  is  much  lessened,  and  it  is  replaced 
by  an  alkaline  fluid  having  no  power  of  digestion. 

Symptoms. — The  initial  morbid  changes,  doubtless,  precede  the  oc- 
currence of  objective  symptoms.  At  first,  diminution  of  appetite, 
labored  digestion,  nocturnal  restlessness,  inability  to  undergo  fatigue, 
supra-orbital  headache  increased  by  light,  by  noises,  and  by  move- 
ments of  the  head,  and  sometimes  accompanied  by  vertigo,  are  the 
symptoms  experienced.  In  some  instances,  the  vertigo  is  extreme  ; 
the  patient  may  fall  unconscious  for  a  few  seconds,  and  the  vertigi- 
nous attacks  may  be  confounded  with  symptoms  of  the  same  kind  due 
to  cerebral  lesions.  Pain  is  felt  at  the  epigastrium,  spontaneous  or 
developed  by  pressure.  The  epigastric  pain  may  have  a  boring  char- 
acter, as  if  passing  through  the  body  straight  to  the  spinal  column,  or 
under  the  angle  of  the  scapulae.  Pain  is  frequently  felt  in  the  left 
hypochondrium,  two  inches  under  the  left  nipple,  or  in  the  immediate 
vicinage  of  the  apex-beat.  The  tongue  is  enlarged,  marked  laterally 
by  the  indentations  of  the  teeth,  and  is  covered  over  its  whole  extent 
with  a  whitish  or  a  yellowish-white  coating.  The  taste  is  perverted, 
indifferent,  bitter,  or  putrid.  Especially  on  rising  in  the  morning  is 
the  mouth  pasty,  sticky,  and  filled  with  a  bitter-tasting  mucus.  The 
appetite  is  totally  lost  (anorexia),  and  the  thought  of  food-taking, 
especially  the  appearance  of  food,  excites  a  sensation  of  disgust ;  but 
considerable  thirst  is  experienced,  and  drinks,  particularly  those  of  an 
acid  character,  are  eagerly  sought  after.  Nausea  is  present  in  varying 
intensity,  and  there  is  usually  vomiting,  at  first  consisting  of  the  ali- 
mentary substances,  then  viscid  mucus  acid  and  bitter,  and  finally 
bilious  matters.  Bilious  vomiting  is  commonly  supposed  to  indicate 
special  disturbance  in  the  hepatic  function,  but  it  really  means  that 
by  the  act  of  vomiting  the  gall-bladder  is  mechanically  compressed, 
and  its  contents  forced  through  the  duodenum  into  the  stomach.  The 
amount  of  vomiting  is  usually  determined  by  the  amount  of  food  pre- 
viously taken.  If  the  result  of  an  indigestion,  the  vomiting  is  copi- 
ous ;  but,  under  other  circumstances,  it  may  occur  only  occasionally, 
aud  then  be  slight.  The  sufferings  of  the  patient  are  always  aggra- 
vated by  errors  of  diet,  and  vomiting  is  certainly  provoked  by  eating 


20  DISEASES  OF  THE  DIGESTIVE   SYSTEM. 

indigestible  food.  A  foul  odor  of  the  breath,  eructations  of  fetid  gas, 
are  due  to  a  failure  of  digestion,  and  the  occurrence  of  decompositions, 
the  character  of  which,  and  the  resulting  products,  being  due  to  the 
kind  of  food  undergoing  this  process.  Saccharine  and  starchy  foods 
become  converted  into  carbonic  and  acetic  acids  ;  the  fatty  result  in 
setting  free  irritating  fat  acids,  and  the  substances  containing  sul- 
phur and  phosphorus  give  forth  the  highly  fetid  compounds  of  hydro- 
gen— sulphuretted  and  phosphuretted  hydrogen  gases.  Acidity  and 
heartburn  (pyrosis)  are  thus  caused,  and  tympanitic  distention  of  the 
stomach  results  from  the  setting  free  of  a  great  quantity  of  carbonic- 
acid  gas.  The  intestinal  functions  may  or  may  not  be  disturbed.  Usu- 
ally there  is  present  slight  constipation  ;  yet,  if  the  attack  is  brought 
on  by  the  use  of  indigestible  aliment,  more  or  less  diarrhoea  may  occur, 
and  it  may  be  conservative.  Mild  cases  of  acute  gastric  catarrh  may 
not  excite  the  least  disturbance  in  the  heat-function,  but  in  young  and 
susceptible  subjects  there  may  be  some  feverishness,  the  movement 
being  of  a  remittent  type,  the  maximum  temperature  rarely  exceeding 
103°  Fahr.  When  the  stomach  disturbance  is  extreme,  and  the  fever 
persists  for  several  days,  the  cases  are  sometimes  entitled  gastric  fever, 
or  they  are  confounded  with  remittent  fever,  especially  in  malarious 
regions. 

Course  and  Duration. — The  duration  of  acute  catarrh  of  the  stom- 
ach is  four  days  to  a  week.  A  sudden  and  rapid  cure  is  sometimes 
effected  by  a  spontaneous  or  a  forced  evacuation,  by  vomiting,  by 
purging,  or  by  a  urinary  discharge.  The  beginning  of  convalescence 
is  sometimes  announced  by  an  eruption  of  herpes,  or  by  a  profuse 
sweat. 

Diagnosis. — Acute  gastric  catarrh  with  fever  may  be  confounded 
with  remittent  and  typhoid  fever  of  the  first  week,  but  all  doubts  will 
disappear  as  these  maladies  develop.  Vertigo  a  stomacho  laeso  (Trous- 
seau) is  to  be  distinguished  from  similar  symptoms  due  to  cerebral 
hyperaemia.  The  distinction  rests  on  the  age  of  the  sixbject,  the  pres- 
ence or  absence  of  degenerative  changes  in  the  vessels,  and  of  the 
arcus  senilis,  the  history  of  stomachal  troubles,  the  fugitive  character 
of  the  symptoms,  and  the  prompt  disappearance  of  the  stomach-disease 
when  efficient  treatment  is  instituted. 

Treatment. — Simple  cases  of  acute  catarrh  of  the  stomach  need  only 
abstinence  and  quiet.  K  the  stomach  is  much  embarrassed,  and  excesses 
of  the  table  have  been  recently  committed,  or  some  specially  irritating 
articles  of  diet  have  been  consumed,  free  emesis  is  the  most  effective 
treatment.  The  salts  of  the  metals  belonging  to  the  class  of  emetics 
are  too  irritating  for  this  purpose.  If  vomiting  have  occurred,  it  may 
be  encouraged  by  swallowing  large  draughts  of  warm  water,  which 
will  act  as  a  sedative  if  the  stomach  is  empty.  Weak  alkaline  mineral 
waters — as  Congress,  Hathorn,  and  Yichy  of  the  Saratoga  Springs, 


TOXIC   GASTRITIS.  21 

and  the  French  Vichy — should  be  drunk  freely.  Unhealthy  and  undi- 
gested aliment,  which  has  reached  the  intestines,  should  be  dislodged 
by  saline  laxatives.  When  there  is  much  biliousness — so  called — 
'  manifested  by  a  heavily-coated  tongue,  vertigo,  headache  frontal  and 
temporal,  yellow  skin,  more  or  less  constipation,  urine  high-colored, 
acid,  scanty,  etc.,  the  mercurial  purgatives  are  held  to  possess  some 
special  curative  powers.  This  is  probably  true  to  a  limited  extent, 
not  because  of  any  action  on  the  liver,  but  because  they  increase  elimi- 
nation from  the  excretory  glands  of  the  lower  ilium.  Podophyllin, 
iridin,  euonymia,  and  ipecac,  are  nearly  equally  effective,  but  calomel 
in  small  doses  (one  twelfth  of  a  grain)  has  remarkable  sedative  effects 
on  an  irritable  stomach.  The  officinal  effervescing  powders,  carbonic- 
acid  water,  milk,  and  lime-water,  are  excellent  remedies  to  check  vom- 
iting. A  mixture  in  equal  parts  of  carbolic  acid  and  iodine  tincture, 
of  which  a  drop  may  be  taken,  well  diluted  with  water,  every  few 
hours,  is  a  most  valuable  remedy  to  arrest  abnormal  fermentations  and 
to  check  vomiting.  A  mixture  of  bismuth  and  carbolic  acid  with  mu- 
cilage, in  mint-water,  is  hardly  less  efficient.  After  the  more  acute 
symptoms  have  subsided,  the  tincture  of  nux-vomica  and  the  diluted 
muriatic  acid  are  suitable  remedies  to  improve  the  tone  of  the  stomach 
and  to  restore  the  appetite. 


TOXIC  GASTRITIS. 

Causes. — As  already  defined,  toxic  gastritis  is  an  acute  inflamma- 
tion of  the  stomach,  caused  by  the  ingestion  of  irritant  and  corrosive 
poisons. 

Symptoms. — So  far  as  the  symptoms  are  concerned,  there  is  no 
essential  difference  in  the  effects  produced  by  the  different  irritant  and 
corrosive  poisons.  Immediately  on  swallowing,  there  ensues  a  deadly 
nausea,  rapid  and  uncontrollable  vomiting,  the  matters  rejected  con- 
sisting of  the  contents  of  the  stomach  acted  on  by  the  poison,  shreds 
of  mucous  membrane,  altered  blood-clots,  etc.  A  diagnosis  of  the 
form  and  chemical  characteristics  of  the  poison  may  sometimes  be 
made  by  observing  the  character  of  the  stain  of  the  face,  lips,  and 
mucous  membrane — sulphuric  acid  causing  a  friable,  blackish  eschar  ; 
nitric  acid  a  yellowish,  leathery  eschar ;  caustic  potash  spreading 
widely,  softening,  and  liquefying  the  tissues.  In  the  stomach,  dark- 
brown,  greenish,  or  black  discolorations,  with  masses  of  sloughing 
mucous  membrane,  are  observed.  It  is  rare  that  the  whole  mucous 
membrane  of  the  stomach  is  uniformly  attacked.  Usually  there  is 
considerable  discoloration — uniform,  indeed,  about  the  cardia,  at  the 
greater  curvature,  and  at  the  pylorus,  leaving  large  portions  un- 
touched. Sometimes  only  the  mucous  membrane  about  the  cardia 
and  at  the  pylorus  is  attacked  (Wilks  and  Moxon)  ;  the  extent  of  the 


22  DISEASES   OF  THE   DIGESTIVE  SYSTEM. 

action  and  the  resulting  appearances  depend  on  the  degree  of  con- 
centration of  the  corrosive  material.  Sometimes  the  walls  of  the 
stomach  are  perforated,  a  result  more  frequently  due  to  the  action  of 
alkalies  than  acids.  The  mineral  poisons — arsenic,  the  salts  of  mer- . 
cury,  copper,  zinc,  nitrate  of  potash,  etc. — produce  an  intense  inflam- 
mation with  vivid  redness  and  injection.  Carbolic  acid  acts  super- 
ficially, and  hardens  and  tans  the  mucous  membrane. 

Similar  results  follow  the  ingestion  of  certain  kinds  of  food  cooked 
in  copper  vessels  and  containing  the  acetate  and  other  salts  of  copper, 
or  articles  of  food  that  have  undergone  decomposition,  such  as  sau- 
sages, hams,  cheese,  fish,  etc.  A  violent  gastro-enteritis  is  produced  in 
a  few  minutes  or  hours  after  the  swallowing  of  such  aliments.  Besides 
the  local  there  are  various  systemic  symptoms,  produced  by  irritant 
poisons,  either  due  to  the  diffusion  of  the  poison  or  to  the  reflex  dis- 
turbance resulting  from  violent  local  irritation.  Besides  the  vomiting 
mentioned  above  as  occurring  immediately  or  very  soon  after  swal- 
lowing the  irritant,  corrosive,  or  toxic  substance,  purging  sets  in,  and 
the  same  sanies,  detritus,  and  sloughs  of  the  tissues  discharged  by 
vomiting  pass  also  by  stool.  In  the  case  of  corrosive  sublimate  and 
the  metallic  salts  generally  there  occur  intense  colic  and  tenesmus,  and 
the  discharges  consist  of  mucus  and  blood,  and  strongly  simulate 
dysentery.  Whether  or  not  diffusion  of  the  poison  or  irritant  takes 
place,  there  occur  great  anxiety  and  depression,  a  weak,  rapid  pulse, 
slow  and  shallow  respiration,  cold  skin,  covered  with  a  cold  sweat, 
retracted  features,  intense  internal  heat  and  thirst,  burning  in  the 
gullet  and  fauces — the  lips,  tongue,  cheeks,  and  fauces,  charred,  cor- 
roded, or  softened  by  the  contact  of  the  poison. 

Course^  Duration,  and  Termination. — The  characteristic  feature  of 
toxic  gastritis  is  the  suddenness  with  which  symptoms  arise,  after 
swallowing  some  solution  or  eating  certain  articles  of  diet.  Soon 
severe  pains  in  the  stomach,  violent  vomiting,  and  other  symptoms 
occur,  the  patient  having  previously  been  in  good  health,  it  may  be. 
Death  may  occur  from  the  immediate  effects  of  the  poison,  from  the 
shock  of  the  injury  done  to  the  organs,  from  the  shock  and  subsequent 
perforation  of  the  stomach,  and  peritonitis,  combined.  Recovery  may 
ensue  if  the  injury  done  is  not  too  great  for  repair,  the  patient  passing 
safely  through  the  period  of  shock  and  collapse.  The  evidences  of 
improvement  consist  in  subsidence  of  the  pain  and  vomiting,  in  re- 
turning tolerance  to  food  which  is  bland  and  unirritating,  in  the  dis- 
appearance of  all  the  symptoms  of  collapse.  Surviving  the  first  injury, 
a  fatal  result  may  be  subsequently  due  to  the  inflammation  which  fol- 
lows. The  convalescence  is  necessarily  tedious,  owing  to  the  very 
limited  surface  capable  of  carrying  on  the  function  of  digestion. 
Recovery  is  apt  to  be  partial,  and  the  nutrition  ever  after  is 
feeble,  owing  to  the  extent  of  injury — the  cicatrices  and  contraction 


CHRONIC   GASTRIC   CATARRH.  23 

of  the  stomach,  the  stenoses  of  the  orifices  of  this  organ,  and  of  the 
(Esophagus. 

Treatment. — Vomiting  is  to  be  encouraged  by  the  free  use  of  de- 
mulcent drinks.  If  the  toxic  agent  consists  of  an  acid,  as  speedily  as 
possible  weak  alkalies,  lime-water,  soda,  common  soap,  etc.,  should  be 
administered.  If  the  offending  substance  is  a  caustic  alkali,  weak 
acids,  common  vinegar,  diluted  acetic  acid,  etc.,  should  be  given.  The 
various  mineral  salts  require  their  appropriate  antidotes :  arsenic, 
dialyzed  iron,  or  hydrated  sesquioxide  of  iron  ;  antimony,  vegetable 
astringents,  as  green  tea,  galls,  and  oak-bark  infusion  ;  mercury  and 
copper,  albumen  and  mucilaginous  substances  ;  phosphorus,  turpen- 
tine, magnesia,  etc.  ;  carbolic  acid,  saccharated  lime.  The  stomach- 
pump  should  be  used  not  only  to  remove  the  poison  remaining,  but  to 
thoroughly  wash  out  the  stomach.  To  allay  pain,  and  counteract  the 
depression  of  the  powers  of  life,  no  agent  is  comparable  to  the  hypo- 
dermatic injection  of  morphia.  Ice  should  be  given  freely,  and  an  ice- 
bag  applied  to  the  epigastrium.  The  morphia  must  be  repeated  at 
regular  intervals.  No  food  should  be  given  but  a  little  cold  milk  at 
short  intervals.  Injections  of  defibrinated  blood  may  be  practiced 
with  great  advantage  as  a  means  of  support.  The  subsequent  man- 
agement depends  on  the  character  of  the  poison,,  and  the  nature  and 
extent  of  the  injuries. 

PHLEGMONOUS  OR  INTERSTITIAL  GASTRITIS. 

Definition. — By  this  term  is  meant  an  inflammation  of  the  walls  of 
the  stomach,  usually  of  the  submucous  layer,  and  resulting  in  the  forma- 
tion of  an  abscess,  or  in  purulent  infiltration  of  the  parietes.  These 
abscesses  may  be  single  or  multiple. 

Causes. — Phlegmonous  gastritis  may  occur  during  the  course  of 
pyaemia,  or  be  due  to  haemorrhagic  infarction  or  to  hepatic  obstruc- 
tion.    These  abscesses  may  be  acute  or  chronic. 

Symptoms. — The  symptomatology  of  phlegmonous  gastritis  is  ex- 
ceedingly obscure.  The  ordinary  course  is  as  follows  :  Usually  sud- 
denly, or  after  an  irregular  prodromal  stage,  the  patient  is  seized  with 
epigastric  pain,  followed  by  nausea  and  vomiting,  thirst,  a  weak  and 
irregular  pulse,  great  distention  of  the  abdomen,  and  dian'hoea.  Pro- 
found prostration  comes  on,  and  finally  a  low  delirium  and  death. 
These  symptoms  do  not  indicate  the  nature  of  the  malady. 

As  it  is  doubtful  whether  such  cases  are  ever  recognized,  the  treat- 
ment must  be  conducted  on  general  principles. 

CHRONIC  GASTRIC  CATARRH. 

Causes. — The  chronic  form  may  succeed  to  the  acute.  Heredity 
exercises  an .  influence  in  its  causation  ;  not  in  the  sense  that  the  dis- 


24  DISEASES  OF   THE  DIGESTIVE   SYSTEM. 

ease  is  directly  traiismitted,  but  the  type  of  mucous  membrane.  Bad 
hygienic  influences  of  every  kind,  especially  miasmatic  influences,  and 
all  manner  of  irregularities  of  life,  are  causative.  The  abuse  of  spir- 
its, and  the  habitual  consumption  of  highly-seasoned  foods  and  of  con- 
diments and  sauces,  hasty  and  insufiicient  mastication,  the  frequent  use 
of  ices,  and  overfeeding,  are  the  principal  causes  of  chronic  gastric 
catarrh. 

Pathological  Anatomy. — The  most  important  changes  occur  about 
the  pylorus.  The  evidences  of  previous  hyperajmia  exist  in  a  brown- 
ish discoloration  due  to  hsemorrhagic  extravasation  and  subsequent 
changes  in  the  hsematin,  and  in  more  or  less  varicosity  of  the  vessels. 
There  is  constantly  present  more  or  less  hypersemia,  but  not  the  intense 
and  vivid  injection  seen  in  acute  catarrh.  The  abnormal  supply  of 
blood  to  the  submucous  connective  tissue  leads  to  overgrowth  (hyper- 
plasia, hypertrophy),  and  this  new  material  contracting,  forces  the 
glands  into  abnormal  prominence,  causing  that  appearance  known  as 
mammelonated  ;  but  it  should  not  be  forgotten  that  this  appearance 
may  be  due  to  a  contraction  of  the  organic  muscular  fiber  without  the 
existence  of  any  disease  whatever.  The  gland-tubules  also  increase  in 
size  in  consequence  of  overgrowth  of  their  contents,  and  they  produce 
a  quantity  of  grayish  or  yellowish,  thick,  tenacious  mucus,  which  cov- 
ers closely  and  adheres  to  the  surface  of  the  mucous  membrane.  The 
overgrowth  of  connective  tissue  increases  the  thickness  of  the  mucous 
membrane  and  its  resistance  to  section.  Compression  of  the  tubules 
(glands),  by  the  contracting  connective  tissue,  induces  atrophy  of  their 
cells.  Here  and  there  a  gland  is  obstructed ;  its  secretion  having  no 
outlet,  accumulates,  and  a  cyst  is  the  ultimate  result. 

Symptoms. — When  a  chronic  succeeds  to  an  acute  catarrh  of  the 
stomach,  the  attacks  of  the  latter  become  increasingly  frequent,  and 
presently  it  is  found  that  the  patient  is  never  free  from  uneasiness  and 
other  painful  sensations  referable  to  the  stomach.  This  painful  and 
otherwise  disordered  digestion  is  commonly  known  as  dyspepsia. 

When  chronic  catarrh  exists  the  patient  is  rarely  free  from  some 
disagreeable  sensations,  but  it  is  after  taking  food,  chiefly,  that  he 
experiences  a  feeling  of  weight  or  fullness,  sometimes  of  pain  ;  but 
acute  pain  of  a  lancinating  character,  especially  when  it  seems  to  pass 
directly  through  to  the  back,  is  more  frequently  due  to  neuralgia — 
gastralgia — or  is  a  symptom  of  ulcer  or  of  cancer.  On  the  other  hand, 
attacks  of  neuralgia  do  sometimes  occur  in  the  course  of  chronic  gas- 
tric catarrh  ;  but  the  pain  of  the  latter  is  more  often  a  sense  of  sore- 
ness diffused  over  the  epigastrium,  the  greater  curvature,  and  is  some- 
times felt  only  in  the  left  hypochondrium.  Sometimes  this  pain  may 
be  relieved  by  pressure  ;  but  more  usually  pressure  over  the  stomach, 
at  any  point,  develops  uneasiness,  soreness,  or  pain.  As  the  pit  of  the 
stomach,  so  called  (the  triangular  space  under  the  xiphoid  appendix),  is 


CHRONIC   GASTRIC   CATARRH.  25 

occupied  by  the  left  lobe  of  the  liver,  and  as  the  stomach  lies  well  up 
in  the  left  hypochondrium,  these  facts  must  be  taken  into  considera- 
tion in  coming  to  a  conclusion  in  regard  to  the  seat  of  pain.  Some- 
times when  the  stomach  is  empty,  sometimes  when  it  is  full,  the  pain 
is  greater  ;  sometimes  the  pain  is  relieved  by  taking  food,  sometimes 
it  is  increased  thereby.  These  idiosyncrasies  give  to  each  case  a  pecu- 
liar physiognomy.  The  subjective  sense  of  fullness  is  confirmed  by 
the  objective  swelling  of  the  stomachal  region.  After  meals,  the  dis- 
comfort caused  by  the  distention  is  such  that  the  mere  pressure  of  the 
clothing  gives  rise  to  pain.  This  feeling  of  distention  is  due  in  part 
to  an  irritable  state  of  the  mucous  membrane,  but  more  especially  to 
the  formation  of  the  gases  of  decomposition.  In  the  normal  state,  the 
gastric  juice  has  the  power  to  prevent  decomposition,  or  to  arrest  it 
after  it  has  begun  ;  but  disease  alters  these  conditions,  and  food  in 
the  stomach  may  pass  through  various  kinds  of  fei'mentation  accord- 
ing to  its  composition — the  starchy  and  saccharine  undergoing  the 
acetic,  and  the  fatty,  the  butyric  fermentation.  A  small  quantity  of 
starch  or  sugar  may  produce  a  large  volume  of  carbonic  acid,  causing 
great  distention,  and  eructations  of  a  sour  liquid  (pyrosis).  Butyric 
acid  induces  a  strong  sense  of  heat  and  burning,  gaseous  eructations, 
often  highly  offensive  from  the  presence  of  sulphur-compounds  with 
hydrogen.  Furthermore,  gaseous  distention  of  the  stomach  affects 
the  muscular  movements  of  the  organ,  so  that  the  foods  are  not  prop- 
erly distributed  and  mixed  with  the  gastric  juice.  In  the  regurgita- 
tions that  ensue,  particles  of  food  are  brought  up,  the  nature  of  which 
is  recognized  by  the  patient ;  it  may  be  acid,  bitter,  or  merely  mawk- 
ish. Again,  by  the  distention  of  the  stomach,  the  heart  is  pushed  up 
and  its  actions  hampered,  and,  through  the  intimate  nervous  commu- 
nications, palpitation  and  intermittent  pulse  and  a  strongly  accentu- 
ated second  sound  are  produced.  In  consequence  of  the  compression  of 
the  great  venous  trunks  the  return  of  blood  from  the  head  is  impeded, 
and  hence  the  face  has  a  congested,  red,  and  swollen  appearance,  and 
the  head  feels  full,  and  headache  and  vertigo  are  present  during  the 
time  the  stomach  digestion  is  going  on.  In  some  cases  of  chronic 
catarrh,  vomiting  of  food  occurs  soon  after  it  is  swallowed.  Later,  if 
vomiting  take  place,  the  food  is  in  various  stages  of  digestion,  and 
the  vomited  matters  are  highly  offensive  from  the  presence  of  butyric 
acid  and  the  sulphur-compounds  mentioned  above.  Sometimes  the 
vomited  matters  will  have  a  pasty  or  yeast-like  appearance,  due  to  the 
presence  of  a  peculiar  fungus — from  its  fancied  resemblance  to  a  wool- 
pack,  called  sarcina  ventriculi.  Vomiting  is  not  constant  nor  regular, 
and  in  many  cases  occurs  only  when  improper  food  has  been  taken. 
On  the  other  hand,  morning  vomiting  of  topers  is  a  constant  and 
ordinary  condition  in  these  subjects.  As  soon  as  they  arise  in  the 
morning  a  feeling   of    qualmishness   comes    on,    and    they   strain   a 


26  DISEASES   OF   THE   DIGESTIVE  SYSTEM. 

great  deal  to  bring  up  some  acid,  glairy,  tough  mucus,  or  a  quantity 
of  rather  thin,  frothy,  watery  fluid  mixed  with  air,  and  alkaline  or 
neutral  in  reaction,  and  consisting  chiefly  of  saliva  swallowed  during 
sleep.  The  appetite  is  usually  diminished,  or  it  may  be  capricious 
and  rarely  excessive  (bulimia).  Usually  but  little  food  in  the  stom- 
ach develops  a  sense  of  satiety.  Certain  kinds  of  food,  by  the  mere 
sight  or  remembrance  of  them,  excite  disgust  and  nausea  ;  and,  as  a 
rule,  the  animal  foods  are  disliked,  and  acid  fruits  and  fresh  vegetables 
are  craved.  The  saliva  is  usually  increased  in  amount ;  the  tongue  is 
pointed,  red  at  the  tip  and  edges,  and  the  mucous  membrane  is 
glazed  ;  the  large  papillse  at  the  base  are  swollen  and  tumefied, 
and  there  is  present  more  or  less  follicular  pharyngitis.  The  intes- 
tinal functions  rarely  continue  undisturbed  ;  constipation  and  flatu- 
lence are  usually  present,  and  the  constipation  alternates  with  diar- 
rhoea. An  extension  of  the  catarrhal  process  from  the  duodenum  to 
the  ductus  communis  and  the  smaller  ducts  causes  more  or  less  swell- 
ing and  obstruction  and,  consequently,  jaundice.  The  nutrition  of 
the  body  is  impaired  by  chronic  gastric  catarrh  ;  the  strength  is  less- 
ened, and  the  subcutaneous  fat  diminishes  ;  the  muscles  lose  in  volume 
and  decline  in  power,  and  the  various  functions  are  performed  with 
less  energy  and  efiiciency.  This  depression  in  the  functions  is  espe- 
cially marked  in  the  psychical  sphere,  where  it  manifests  itself  in 
melancholy  and  hypochondria,  the  patient  being  solely  occupied  with 
his  own  miseries,  and  especially  with  those  sensations  and  feelings 
belonging  to  his  own  state.  The  peculiar  troubles  of  this  mental  state 
are  enhanced  by  the  headache,  the  vertigo,  and  the  other  cerebral 
symptoms  which  accompany  stomachal  diseases. 

Diagnosis. — The  coexistence  of  the  cerebral  symptoms  just  men- 
tioned with  those  of  chronic  gastric  catarrh  may  greatly  embarrass 
the  diagnosis,  but  usually  the  differentiation  may  be  made  by  refer- 
ence to  the  history  of  the  case,  the  extended  duration  of  the  gastric 
symptoms,  which  is  incompatible  with  the  fact  of  a  cerebral  malady, 
and  the  absence  of  concomitant  evidences  of  disease  of  the  nervous 
centers.  Ulcer  of  the  stomach  may  be  confounded  with  chronic  gas- 
tric catarrh,  but  the  diagnosis  may  be  made  by  attention  to  the 
following  points  :  In  ulcer,  there  is  in  front  a  fixed  point  of  pain, 
posteriorly  a  corresponding  j^ainful  spot  ;  there  is  no  diffused  sore- 
ness ;  there  is  acute  pain  as  well  as  soreness  ;  the  pain  is  aggravated 
by  pressure,  by  the  ingestion  of  solids  and  liquids,  especially  if  hot  or 
cold  ;  there  is  vomiting  of  blood.  In  cancer,  there  is  pain  acute  or, 
lancinating  or  burning,  when  the  stomach  is  empty  or  full  ;  vomiting 
of  food,  of  glairy  mucus  tinged  with  blood,  and  vomiting  of  black 
blood  ;  rapid  and  continuous  emaciation  ;  a  peculiar  icteroid,  earthy 
hue  ;  a  tumor,  hard  or  with  nodosities  ;  enlargement  of  exteraal 
glands  (the  sub-clavicular). 


CHRONIC   GASTRIC   CATARRH.  27 

Course  and  Duration. — The  duration  of  chronic  gastric  catarrh  is 
very  variable  ;  it  may  last  months  or  years,  now  better,  now  worse, 
depending  on  the  measures,  or  the  neglect  of  them,  employed  for 
relief.  Readily  enough  cured,  if  the  patient  will  submit  to  the  regi- 
men necessary,  it  becomes  exceedingly  difficult  if  the  causes  which 
produced  it  continue  in  operation.  Catarrh  may  terminate  in  ulcer, 
or  it  may  lead  to  stenosis  of  the  pylorus. 

Treatment. — The  ti-eatment  of  chronic  gastric  catarrh  due  to  he- 
patic obstruction,  to  valvular  disease  of  the  heart,  and  to  albuminuria, 
belongs  to  the  management  of  these  diseases  respectively,  and  need 
not  be  considered  here. 

Regulation  of  the  diet  is  of  the  first  consequence  in  all  stomach 
diseases.  All  articles  that  disagree,  whether  owing  to  their  nature  or 
to  idiosyncrasy,  should  be  omitted.  As  acetic-  and  butyric-acid  fermen- 
tations play  so  important  a  part  in  stomach  derangements,  it  is  highly 
important  to  exclude  from  the  diet  those  substances  the  decomposition 
of  which  results  in  the  formation  of  these  acids.  These  articles  of  diet 
are  the  saccharine,  the  starchy,  and  the  fatty.  The  mucus  acts  as  a 
ferment,  and  these  decomposing  substances  enact  the  same  rdle,  so 
that,  when  the  starches,  sugars,  and  fats,  reach  the  stomach,  the  fer- 
mentation begins.  To  exclude  these  articles,  then,  is  the  first  step 
toward  a  cure.  In  lieu  of  these  components  of  the  diet,  so  important 
to  most  persons,  the  succulent  vegetables,  as  lettuce,  celery,  spinach, 
cauliflower,  tomatoes,  etc.,  should  be  substituted.  The  materials  for 
continuing  the  fermentations,  consisting  of  mucus  and  the  remains  of 
previous  fermentation,  must  be  removed  from  the  cavity,  if  a  continu- 
ance of  the  disorder  is  to  be  prevented.  This  can  be  accomplished  in 
several  ways  :  by  the  use  of  an  absolute  diet  until  the  organ  has  freed 
itself  of  its  decomposing  contents  ;  by  the  administration  of  emetics 
and  laxatives  ;  by  washing  out  the  organ  with  the  stomach-pump;  and, 
lastly,  by  the  employment  of  certain  medicines.  A  curative  measure 
of  the  highest  importance  is  the  "  skim-milk  cure."  This  consists  in 
the  exclusive  use  of  milk  for  food  until  the  stomach  is  freed  from  the 
materials  of  fermentation,  and  has  had  sufficient  rest  to  recover.  The 
milk  is  taken  in  the  quantity  of  four  ounces  (about)  every  three  hours, 
day  and  night,  when  awake,  and  for  a  period  of  time  determined  by 
the  cessation  of  the  symptoms  for  which  it  was  prescribed.  During 
this  time  nothing  whatever  is  swallowed,  except  a  laxative  to  relieve 
the  constipation,  or  medicine  for  other  purposes  ;  but  no  medicines 
should  be  administered  during  a  course  of  the  milk-cure,  unless  impera- 
tively demanded.  When,  after  a  few  weeks,  or  a  month  or  two,  the 
symptoms  of  gastric  catarrh  have  subsided,  then  some  additions  to  the 
diet  may  be  made,  very  gradually,  consisting  at  first  of  a  little  stale 
white  bread,  then  rice,  then  a  soft-boiled  Qgg,  and  so  on,  gradually, 
until  a  suitable  diet  is  constructed. 


28  DISEASES   OP   THE   DIGESTIVE   SYSTEM. 

An  emetic,  occasionally,  is  highly  useful  to  empty  the  stomach  of 
decomposing  materials,  and  to  prepare  a  clean  surface  for  the  action 
of  medicaments.  Saline  laxatives  may  be  employed  for  the  same  pur- 
pose. An  occasional  Sedlitz  powder  ;  now  and  then  a  drachm  or  two 
of  Epsom  salts  in  the  early  morning,  or  the  Saratoga  waters,  or  Ptlllna, 
or  Friederichshall,  etc.,  are  appropriate  for  this  purpose.  When  there 
is  much  biliary  derangement,  phosphate  of  soda  is  highly  serviceable. 
Still  more  effective  for  cleansing  the  stomach  is  the  stomach-pump, 
or  the  fountain-syringe  used  as  a  siphon.  With  this  instrument  the 
cavity  may  be  thoroughly  washed  out  with  tepid  water,  solution  of 
common  salt,  solution  of  potassic  chlorate,  solution  of  salicylic  acid, 
etc.  As  the  effects  are  mechanical,  chiefly,  and  are  due  to  mere  wash- 
ing of  the  mucous  membrane,  it  usually  suflaces  to  employ  warm 
water.  In  severe  cases  the  irrigation  of  the  stomach  may  be  practiced 
daily. 

Arsenic  is  a  remedy  of  the  first  importance  in  the  treatment  of 
catarrh  of  the  stomach.  It  is  best  administered  in  the  form  of  Fow- 
ler's solution,  one  or  two  drops,  three  times  a  day  before  meals,  and  it 
should  be  continued  for  a  month  or  more.  Next  to  arsenic,  the  oxide 
of  silver  is  to  be  commended,  in  pill  form,  one  half  to  one  grain,  three 
times  a  day,  also  administered  on  an  empty  stomach  ;  but,  as  argyria 
may  follow  its  prolonged  use,  it  should  not  be  given  for  a  longer  time 
than  one  month.  When  there  is  much  acidity,  it  may  be  checked  by 
the  mineral  acids,  notably  the  muriatic,  given  before  meals.  This 
practice  is  based  on  the  principle  that  acids  before  meals  prevent  the 
osmosis  of  those  constituents  of  the  blood  which  contribute  to  form 
the  acid  gastric  juice.  Alkalies,  although  they  afford  relief,  do  not 
effect  a  cure,  except  in  those  cases  of  acidity  of  a  temporary  character 
due  to  fermentation  of  starchy  and  saccharine  food,  and  accompanied 
by  catarrh  of  the  bile-ducts,  and  then  the  alkali  most  effective  is 
the  phosphate  of  soda.  When  acid  is  deficient,  good  results  may  be 
obtained  by  the  use  of  alkalies  before  meals,  on  the  well-recognized 
principle  that  an  alkaline  fluid  in  the  stomach  will  favor  the  diffusion 
from  the  blood  of  its  acid-forming  constituents.  When  abnormal 
fermentations  constitute  the  chief  or  only  source  of  discomfort,  the 
most  serviceable  remedy  is  carbolic  acid,  alone  or  in  combination  with 
bismuth.  Gaseous  eructations  are  best  relieved  by  the  same  means. 
Freshly  bumed  charcoal,  finely  divided,  is  a  good  remedy,  though  only 
palliative,  acting  merely  as  an  absorbent.  After  suitable  treatment 
for  the  relief  of  the  local  condition,  tincture  of  nux  vomica  is  an  ex- 
cellent stomachic,  especially  adapted  to  the  chronic  catarrh  of  spirit 
drinkers.  The  bitters  in  general,  with  or  without  the  mineral  acids, 
are  applicable  under  the  same  conditions.  It  should  never  be  forgot- 
ten that  all  special  stimulants  to  the  gastric  mucous  membrane  are 
injurious,  and  should  never  be  employed  until  the  morbid  state  is 


ATONIC  DYSPEPSIA.  29 

removed.  To  employ  them  without  proper  regulation  of  the  diet  is 
simply  to  add  another  source  of  irritation.  It  can  not  be  too  strongly 
impressed  on  the  reader  that  rest,  which  is  essential  to  the  treatment 
of  any  diseased  organ,  is  equally  necessary  to  the  stomach  when  it  is 
suffering  ;  but,  as  some  aliment  is  absolutely  necessary  to  life,  the 
stomach  can  never  be  put  into  a  state  of  complete  repose.  Hence  the 
need  of  a  most  careful  regulation  of  the  diet,  so  that  the  condition  of 
rest  may  be,  as  nearly  as  possible,  attained. 

ATONIC  DYSPEPSIA. 

Definition. — By  atonic  dyspepsia  is  meant  a  form  of  indigestion 
due  to  a  depressed  state  of  the  stomach.  It  is  that  form  of  functional 
derangement  usually  called  dyspepsia. 

Causes. — It  is  often  inherited.  It  is  a  disease  of  advanced  life,  and 
is  then  accompanied  by  those  senile  changes  belonging  to  that  period, 
and  is  a  consequence  of  them.  It  is  a  symptom  in  depressed  states  of 
the  system  generally,  as,  for  example,  in  exhausting  discharges,  as 
haemorrhages,  leucorrhoea,  profuse  suppuration,  etc.  It  is  produced 
by  all  those  circumstances  comprehended  under  the  term  bad  hygiene. 
The  most  influential  factors  are  improper  and  excessive  alimentation, 
and  severe  mental  and  physical  exertion  immediately  after  eating. 

Morbid  Anatomy. — This  malady  has  not,  properly  speaking,  a  mor- 
bid anatomy  :  besides  anaemia  and  deficient  secretion,  there  are  no 
changes.  Various  alterations  have  been  noted,  as  atrophy  of  the  tu- 
bules, fatty  degeneration,  increase  of  the  connective  tissue,  etc.  But 
these  changes  belong  to  other  states,  of  which  atonic  dyspepsia  is 
merely  a  symptom. 

Symptoms. — A  sense  of  weight  and  uneasiness,  lasting  throughout 
the  process  of  digestion,  suspended  for  a  short  period  when  food  is 
taken,  is  usually  the  initial  symptom.  A  feeling  as  if  a  foreign  body 
were  lodged  behind  the  sternum,  or  higher  up  in  the  oesophagus,  often 
with  a  sense  of  oppression  or  dyspnoea,  is  frequently  experienced. 
Acute  pain  is  rarely  felt,  but  there  is  usually  some  flatulent  colic,  and 
pressure  fails  to  develop  pain,  but  rather  affords  relief  to  uneasy  sen- 
sations. Digestion  is  impaired  in  respect  to  all  classes  of  foods,  fari- 
naceous, saccharine,  and  fatty  ;  and  hence,  during  the  process  of  diges- 
tion, flatulence  from  the  formation  of  carbonic  acid  and  eructation  of 
rancid  fats  are  frequently  present.  More  or  less  intestinal  disturbance 
accompanies  the  stomach  symptoms,  and  constipation  almost  always 
occurs.  The  appetite  is  usixally  feeble,  and  the  disinclination  for  food 
includes  all  the  varieties.  There  is  little  thirst,  and  the  ingestion  of 
fluid  gives  rise  to  distress.  The  tongue  is  too  large,  and  is  marked 
along  its  borders  by  the  teeth,  and  is  at  the  same  time  pale  and  flabby. 
The  mucous  membrane  of  the  mouth  is  also  pale  and  the  gums  are  soft 


30  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

and  spongy  ;  the  tonsils  are  apt  to  be  enlarged,  the  uvula  relaxed,  the 
voice  husky,  and  there  is  frequent  clearing  of  the  throat.  The  bodily 
condition  generally  is  that  of  depression  ;  the  pulse  is  weak,  excitable, 
and  easily  compressed  ;  palpitation  occurs  quickly  on  exertion  and  fre- 
quently without  effort  of  any  kind,  and  intermission  of  the  pulse-beat 
is  by  no  means  uncommon.  Flatulent  distention  of  the  abdomen  in- 
duces oppression  of  the  chest,  but  dyspnoea  may  occur  without  such 
cause,  being  due  to  a  nervous  state.  The  skin  is  usually  pallid  and 
earthy,  moist  and  clammy,  and  the  extremities  cold.  The  urine  is 
pale,  of  low  specific  gravity,  and  loaded  with  the  phosphates.  The 
mental  condition  is  in  harmony  with  the  general  state — that  is,  de- 
pressed. There  is  great  inaptitude  for  mental  exertion,  an  impaired 
state  of  the  memory  and  attention,  and  irritability  of  temper.  Drow- 
siness supervenes  after  eating,  while  sleep  at  night  is  restless  and  un- 
refreshing. 

Diagnosis. — Atonic  dyspepsia  differs  from  chronic  gastric  catarrh 
in  respect  to  the  amount  of  pain,  vomiting,  and  tenderness  on  pressure, 
which  are  less,  and  the  depression  which  is  greater,  in  the  former  than 
in  the  latter. 

Treatment. — In  this  as  in  other  stomach  disorders,  the  first  step  con- 
sists in  regulation  of  the  diet.  It  is  useful  to  commence  the  dietetic 
management  by  the  milk-cure.  Next,  as  rapidly  as  possible,  nutritious 
but  easily  digested  articles  must  be  added.  As  the  digestive  powers 
are  feeble,  food  must  be  given  in  small  quantity  but  frequently.  As 
the  foods  disagree,  irrespective  of  their  quality,  obviously  quantity 
and  frequency  of  ingestion  are  the  points  to  be  considered.  As  the 
powers  of  digestion  are  depressed,  the  special  aids  to  this  function  are 
indicated  :  pepsine,  lacto-pepsine,  in  combination  with  muriatic  acid  ; 
pepsine  and  bismuth  with  aromatic  powder  ;  tincture  of  nux  vomica, 
strychnia,  and  the  bitters,  especially  calumba,  with  or  without  muriatic 
acid  ;  the  mild  chalybeates,  as  pil.  ferri  carb,,  the  citrate,  malate,  or 
tartrate  of  iron,  etc.,  are  the  most  appropriate  of  the  medical  agents. 
A  small  quantity  of  acid  wine  at  dinner  is  a  good  stimulant  to  the 
digestive  function.  A  moderate  dose  of  whisky,  taken  before  meals, 
is  a  capital  remedy  to  promote  the  appetite  and  the  digestion  ;  but  it 
is  a  dangerous  remedy,  for  it  so  overcomes  the  feeling  of  depression 
as  to  be  very  grateful,  and  there  is  therefore  a  constant  temptation  to 
repeat  the  dose.  As,  in  these  cases,  there  is  usually  more  or  less  men- 
tal depression,  change  of  scene,  travel,  and  agreeable  occupation,  con- 
tribute materially  to  the  cure. 


GASTRALGIA. 

Definition. — Gastralgia  is  a  painful  state  of  the  sensory  nerves  of  the 
stomach,  induced  by  various  sources  of  irritation,  and  free  from  fever. 


GASTRALGIA.  31 

Causes. — Doubtless  the  chief  factor  is  a  peculiar  state  of  the  ner- 
vous system,  the  neurotic  temperament,  so  called,  or  the  nervous  state, 
or  hysteria.  This  condition  of  the  nerves  existing,  various  substances, 
which  under  ordinary  circumstances  would  not  excite  the  least  distress, 
now  cause  severe  paio.  It  is  highly  probable  that  the  abuse  of  tea  and 
coffee  has  no  little  influence  in  causing  the  disease. 

Symptoms. — The  characteristic  symptom  of  gastralgia  is  the  occur- 
rence of  severe  paroxysmal  pain,  felt  in  greatest  intensity  at  or  about 
the  epigastrium,  and  radiating  thence  upward  over  the  chest  and  down- 
ward through  the  abdomen.  The  pain  also  is  felt  in  the  back,  and 
seems  to  pierce  through  the  body,  and  it  shoots  upward  to  the  shoul- 
ders. The  pain  is  not  increased  but  diminished  by  pressure,  and  the 
patient  instinctively  lies  or  presses  firmly  on  the  abdomen,  or  demands 
to  be  rubbed  or  beaten  on  the  back.  In  the  severest  cases,  the  pain  is 
so  excessive  as  to  produce  profound  prostration  ;  the  pulse  is  small, 
rapid,  and  weak,  the  surface  is  cold  and  covered  with  a  cold  sweat, 
and  the  features  are  shrunken.  In  almost  all  cases,  the  action  of  the 
heart  is  disturbed,  owing  to  the  intimate  nervous  communications  be- 
tween the  two  organs  ;  the  pulse  is  small  and  weak  or  intermitting. 
The  duration  of  the  attacks  is  very  variable,  lasting  for  a  few  hours, 
for  a  day  or  two,  or  continuing  for  months  vrith  intermissions  and 
remissions.  Usually  the  attacks  are  of  short  duration,  and  terminate 
with  eructations  of  gas,  with  vomiting,  or  the  more  acute  pain  subsides, 
leaving  a  sense  of  soreness,  and  occasional  lighter  pains,  which  may 
continue  for  several  days.  The  attacks  may  be  regularly  intermittent, 
in  cases  of  uterine  disease,  and  when  caused  by  malaria.  During  the 
interval,  the  function  of  digestion  may  proceed  undisturbed,  and  the 
nutrition  of  the  body  continue  at  the  normal.  Various  disorders  of 
the  nervous  system  are  usually  present,  as — palpitations,  migraine, 
hysterical  phenomena,  notably  the  globus,  etc.  In  males,  hypochon- 
dria, associated  with  oxaluria,  is  not  infrequent. 

Course  and  Duration. — Gastralgia  is  an  essentially  chronic  malady, 
in  that  the  attacks  are  prone  to  return  from  time  to  time,  and  the  as- 
sociated disorders  continue  in  the  interim  to  plague  the  patient.  Those 
cases  dependent  on  malaria,  or  on  the  presence  of  indigestible  food, 
may  be  cured  with  comparative  facility,  but  the  ordinary  cases  are  not 
readily  cured.  Notwithstanding  the  obstinacy  of  these  cases,  gastral- 
gia is  not  dangerous  to  life. 

Diagnosis. — Gastralgia  is  to  be  differentiated  from  myalgia  affect- 
ing the  abdominal  muscles,  intercostal  neuralgia,  hepatalgia,  neuralgia 
of  the  solar  plexus,  ulcer  of  the  stomach,  and  cancer.  In  myalgia  the 
pain  is  restricted  to  the  affected  muscles,  and  has  not  the  acute  and 
lancinating  character  of  gastralgia,  and  is  unaccompanied  by  nausea 
and  vomiting.  As  respects  intercostal  neuralgia,  it  is  to  be  noted  that 
the  pain  is  in  the  left  hypochondrium,  that  painful  points  can  be  de- 


32  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

veloped  by  pressure  in  the  course  of  the  nerve-trunk,  and  at  the  spine, 
and  that  this  affection  is  unaccompanied  by  nausea  and  vomiting.  To 
separate  gastralgia  from  neuralgia  of  the  solar  plexus  is  in  some  cases 
extremely  diiRcult ;  but  attention  to  the  following  points  may  prevent 
error  :  in  gastralgia,  there  is  a  history  of  previous  stomachal  disorders; 
in  neuralgia  of  the  solar  plexus,  the  inhibition  of  the  heart's  action  is 
greater,  and  the  systemic  depression  is  more  profound.  Hepatalgia 
and  hepatic  colic  are  to  be  separated  by  the  situation  of  the  pain  in  the 
left  hypochondrium,  by  the  tenderness  in  the  region  of  the  gall-blad- 
der, by  the  symptomatic  fever,  and  by  the  jaundice.  From  cancer, 
gastralgia  is  differentiated  by  the  age  of  the  subject,  by  the  character 
of  the  vomited  matters,  the  persistence  of  the  pain,  the  cachexia,  the 
emaciation,  and  the  tumor  ;  from  ulcer,  by  the  fixedness  of  the  pain, 
its  constant  presence  with  soreness,  the  vomiting  of  blood,  etc. 

Treatment. — During  a  paroxysm,  the  first  point  is  the  relief  of 
pain.  This  may  be  most  effectively  and  promptly  accomplished  by 
the  hypodermatic  injection  of  morphia,  and  frequently  so  small  a  dose 
as  one  twelfth  of  a  grain  suffices.  As  there  is  always  danger  of  opium- 
habit  in  these  cases,  this  fascinating  remedy  must  be  used  with  cau- 
tion. Opium  or  morphia  is  frequently  prescribed  with  bismuth  and 
aromatic  powder.  Morphia  is  also  used  endermically — that  is,  applied 
to  a  blistered  surface,  about  a  square  inch  of  surface  being  denuded. 
By  enema  is  an  efiicient  mode  of  administering  the  anodyne.  When, 
from  any  cause,  morphia  can  not  be  given,  the  pain,  as  also  the  nausea 
and  vomiting,  may  be  ari-ested  by  creosote  or  carbolic  acid.  This 
remedy  may  also  be  administered  with  bismuth  in  an  emulsion — a 
combination  of  the  most  efficient  kind.  Equal  parts  of  tincture  of 
iodine  and  carbolic  acid,  of  which  a  drop  may  be  administered  every 
hour  in  a  little  cold  water,  is  a  most  valuable  agent,  not  only  for  the 
relief  of  pain,  but  to  stop  the  vomiting.  Arsenic  (one  drop  of  Fow- 
ler's solution)  and  opium  (two  to  five  drops  of  the  tincture)  are  not 
unfrequently  highly  serviceable  for  the  relief  of  the  paroxysms,  but 
they  are  more  generally  useful  for  the  accompanying  condition  of  the 
mucous  membrane,  and  the  end  organs  of  the  nerves  of  the  stomach. 
There  is  no  remedy  so  constantly  curative  of  the  local  causes  of  the 
attacks,  and  so  efficient  in  preventing  their  return,  as  arsenic.  For 
the  condition  of  things  between  the  attacks,  next  to  arsenic,  stand  the 
oxide  and  nitrate  of  silver.  For  the  strictly  intermittent  cases,  occur- 
ring at  a  fixed  hour,  quinine  is  invaluable  ;  but  the  author  has  seen 
cases  which  were  not  removed  by  quinine,  but  ceased  promptly  when 
salicylic  acid  was  administered.  When  attacks  of  gastralgia  are  due 
to  indigestible  food,  the  first  duty  is  to  empty  the  stomach.  If  vomit- 
ing is  going  on,  it  may  be  encouraged  by  large  draughts  of  warm 
water  ;  if  vomiting  has  not  occurred,  it  should  be  induced  by  an 
emetic,  preferably  by  apomorphia  administered  hypodermatically,  to 


ULCER   OF   THE   STOMACH.  33 

avoid  irritation  of  the  stomach.  If  acid  and  fermenting  materials  re- 
main to  keep  up  the  disturbance,  they  should  be  removed  by  irrigation 
of  the  stomach,  or  by  mild  laxatives  of  the  saline  and  antacid  charac- 
ter. It  is  generally  better  to  remove  the  contents  of  the  stomach  be- 
fore administering  anodynes.  The  subjects  of  gastralgia  are  usually 
of  the  nervous,  hysterical,  and  hypochondriacal  type,  and  require 
chalybeate  and  supporting  remedies.  As  the  stomach  in  such  sub- 
jects is  easily  offended,  only  the  milder  preparations  of  iron  can  be 
giyen — such  as  the  carbonate,  the  citrate,  lactate,  etc.  ;  but,  in  some 
persons  of  a  habit  feeble  and  relaxed,  the  more  astringent  prepara- 
tions do  better — for  example,  the  sulphate  and  the  chloride.  Excel- 
lent results  are  often  obtained  from  the  use  of  the  mineral  acids,  nota- 
bly the  muriate,  and  especially  when  administered  conjointly  with  the 
tincture  of  nux  vomica  (Fox).  The  long-continued  use  of  arsenic 
in  a  small  dose — one  drop  ter  in  die  of  Fowler's  solution — is  more 
effective,  according  to  the  author's  experience,  than  any  remedy  men- 
tioned. As  attacks  of  gastralgia  are,  very  frequently  at  least,  excited 
by  indigestible  food,  it  is  highly  important  to  regulate  the  diet.  Fur- 
thermore, in  these  subjects  the  digestion  has  been  enfeebled  by  the 
depressed  state  of  the  nervous  system.  The  best  results  are  therefore 
obtained  by  a  careful  regulation  of  the  hours  of  eating,  the  quality  of 
the  food,  and  the  mental  and  bodily  exercise.  In  most  cases,  proba- 
bly, the  treatment  should  be  begun  by  the  milk-cure,  and  subsequent- 
ly a  dietary  should  be  constructed  suitable  to  the  needs  of  individual 
cases.  In  some  instances,  the  frequent  use  of  a  small  amount  of  food 
is  more  serviceable  than  the  taking  of  ordinary  meals.  When  the 
digestion  is  feeble  merely,  pepsin  and  lactic  or  muriatic  acids  are  most 
useful.  When  acidity  and  heartburn  exist,  due  to  the  fermentation 
of  the  starches  and  sugars,  the  mineral  acids  must  not  be  given  after 
meals,  but  before,  for  physical  reasons  already  explained. 


ULCER   OF  THE   STOMACH. 

Definition. — By  the  term  ulcer  is  meant  a  solution  of  continuity 
involving  the  mucous  membrane  and  one  or  more  of  the  layers  of 
which  the  wall  of  the  stomach  is  composed,  with  defined  margins  hav- 
ing a  greater  thickness  than  the  adjacent  healthy  tissues.  Sympto- 
matically,  the  stomach-ulcer  is  characterized  by  pain,  disorders  of 
digestion,  and  vomiting  of  blood. 

Causes. — Ulcer  of  the  stomach  is  a  comparatively  common  disease, 
and  is  found  to  exist  in  five  per  cent,  of  the  deaths  from  all  causes. 
It  is  present  in  proportionately  greater  numbers  after  thirty-five,  be- 
cause it  is  an  essentially  chronic  malady  ;  but  it  is,  really,  more  fre- 
quent in  youth  and  middle  life,  from  fifteen  to  thirty,  and  it  is  com- 
paratively often  seen  in  housemaids  of  twenty — an  age,  too,  at  which 
3 


34  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

rupture  occurs  in  greater  proportion  than  at  any  other.  It  is  probable 
also  that  women  are  more  subject  to  the  disease  than  men,  and  that 
rupture  occurs  more  frequently  in  the  former  than  in  the  latter.  The 
most  influential  factors  in  its  pathogeny  are,  variation  in  the  tonus  of 
the  gastric  vessels  and  mechanical  arrest  of  the  circulation  at  the 
point  where  the  ulcer  forms  (thrombosis,  embolism).  There  is  usu- 
ally, in  these  cases,  disease  of  the  arterial  tunics  (atheroma  and  endar- 
teritis), which  finally  causes  coagulation  of  the  blood  and  arrest  of  the 
blood-stream  in  a  nutritious  artery  ;  obstruction  of  the  portal  circula- 
tion may  induce  thrombosis,  hsemorrhagic  infiltration,  etc.  The  result 
of  a  sudden  and  severe  diminution  in  the  amount  of  blood  passing  to 
a  part,  or  of  its  entire  arrest,  is  to  diminish  the  alkalescence  of  the 
deeper  layers  of  the  mucous  membrane,  and  to  permit  the  corrosive 
and  solvent  action  of  the  gastric  juice.  It  has  long  been  recognized 
that  amenorrhoea,  anaemia,  chlorosis,  the  puerperal  state,  prolonged 
lactation,  and  tuberculosis,  are  also  etiological  factors,  and  probably 
because,  in  these  states,  a  necrotic  process  is  readily  induced,  under 
favorable  local  conditions. 

Irritation  of  certain  parts  of  the  brain  is  followed  by  ecchymoses 
and  erosions  of  the  mucous  membrane  of  the  stomach.  Burns  of  the 
chest  and  abdomen  sometimes  cause  ulceration  of  the  duodenum.  A 
peculiar  state  of  the  nervous  system  must,  therefore,  be  regarded  as 
one  of  the  causes  of  this  disease. 

Pathological  Anatomy. — Ulcers  corresponding  in  every  respect  to 
those  of  the  stomach  are  found  rarely  at  the  lower  part  of  the  oesopha- 
gus, at  the  first  part  of  the  duodenum  (associated  with  burns  on  the 
surface),  and  in  the  caecum,  as  the  author  has  shown.  In  twenty  per 
cent,  of  the  cases  of  stomach-ulcer,  they  are  multiple,  but  rarely  as 
many  as  five  existing  at  one  time  ;  in  eighty  per  cent,  of  the  cases, 
the  ulcer  is  solitary.  Not  all  parts  of  the  stomach  are  equally  liable 
to  the  ulcerative  process.  In  four  fifths  of  all  cases  the  ulcer  or 
ulcers  are  found  on  the  posterior  wall,  the  lesser  curvature,  and  about 
the  pylorus.  In  size  they  vary  greatly,  according  to  age,  and  prob- 
ably, according  to  their  nature  ;  but  they  are  not  smaller  than  a  dime, 
and  never  attain  greater  dimensions  than  six  inches  by  three.  In 
shape  they  are  round  or  oval,  more  frequently  round.  So  great  is  the 
difference  in  size,  quality,  and  appearance  between  the  so-called  acute 
perforating  ulcer  and  the  round,  indurated,  and  chronic  ulcer,  that  it 
is  difiicult  to  realize  that  they  are  merely  stages  of  the  same  process. 
The  former  is  about  the  size  of  a  dime,  or  shilling-piece,  is  round  and 
has  smooth  edges  without  induration  and  increased  thickness,  fre- 
quently covered  with  a  clot  or  containing  a  mass  of  slough  adherent, 
and  extending  in  depth  to  the  submucous  connective  tissue.  Ulcers 
of  this  description  are  usually  found  in  young  subjects — housemaids, 
notably — have  a  great  tendency  to  perforate,  and  are  not  unfrequently 


ULCER   OF  THE   STOMACH.  35 

produced  by  obstruction  to  the  portal  circulation  (hemorrhagic  ero- 
sion, thrombosis,  etc.).  The  latter  or  chi-onic  form  is  large  in  size, 
having  walls  of  great  thickness  and  indurated,  composed  of  connec- 
tive and  granulation  tissue  deposited  at  various  times,  giving  to  it  a 
stratified  appearance.  After  many  years,  such  an  ulcer  presents  a 
crater-like  aspect,  with  shelving  sides,  and  terminates  by  a  small  apex 
in  muscular,  sub-muscular,  or  peritoneal  layer,  or  in  a  perforation. 
The  connective  and  granulation  tissue,  of  which  the  crater-like  inter- 
nal surface  is  composed,  is  also  deposited  at  the  base,  and  in  this  way 
perforation  is  prevented.  Facts  are  wanting  to  demonstrate  an  inter- 
mediate or  transition  stage  between  the  two  forms  of  stomach-ulcer. 
In  the  course  of  development  of  the  chronic  ulcer,  the  anatomical  ele- 
ments of  the  mucous  membrane,  including  the  tubular  glands,  are 
destroyed,  and  in  rare  instances  villous  or  jjolypoid  growths  appear  in 
the  neighborhood  of  the  new  formation.  In  very  rare  instances  the 
mucous  membrane  may  be  largely  preserved,  and  the  ulcerative  action 
excavate  a  cavity  beneath.  Several  small  ulcers  may  coalesce,  unite 
in  their  long  diameters,  and  thus  form  an  oval  excavation  along  the 
lesser  curvature,  or  make  a  girdle  around  the  pylorus.  Ulcers  of  the 
stomach  tend  to  spontaneous  cure.  In  many  instances  of  death  from 
other  causes,  ulcers,  either  healing  or  cicatrized,  have  been  found, 
when  no  symptoms  had  existed  during  life,  in  any  sense  indicative  of 
their  presence.  In  the  process  of  cicatrization,  if  the  ulceration  has 
not  extended  beyond  the  muscular  layer,  the  repair  is  by  union  of 
granulations,  and  the  cicatrix  forms  a  puckered  depression.  When 
there  is  more  extensive  loss  of  substance,  involving  all  but  the  perito- 
neal layer,  there  is  very  great  contraction,  and  a  large  cicatrix  with 
radiating  lines  of  thickened  connective  tissue.  The  peritoneal  surface 
is  drawn  in,  giving  to  that  membrane  a  puckered  appearance.  If  the 
ulcer  had  been  large,  oblong,  and  formed  by  the  coalescence  of  several 
smaller  ulcers,  and  situated  near  the  pylorus,  narrowing  of  that  ori- 
fice, and  consequent  dilatation  of  the  rest  of  the  organ,  would  be 
necessary  results.  Sometimes  the  base  of  the  ulcer  forms  adhesions  to 
neighboring  organs  in  the  process  of  cicatrization,  causing  ever  after- 
ward serious  interference  with  the  movements  of  the  stomach,  and 
therefore  impairing  its  functions.  Secondary  cavities  are,  occasion- 
ally, formed  by  a  local  peritonitis  arising  from  perforation,  the  con- 
tents of  the  stomach  being  prevented  escaping  into  the  general  cavity 
of  the  peritonaeum  by  a  limiting  inflammation  which  secures  firm  adhe- 
sion to  neighboring  organs,  to  the  omentum,  pancreas,  liver,  the  adja- 
cent lymphatics,  the  transverse  colon,  the  kidneys,  the  diaphragm,  and 
the  abdominal  walls.  If  cicatrization  takes  place  after  these  attach- 
ments have  formed  to  adjacent  organs,  they  are  embraced  in  the  cica- 
tricial tissue,  and  very  great  deformity,  with  serious  impairment  of 
function,   may  result.     Unfortunately,   these    conservative   adhesions 


36  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

are  not  always  formed  :  the  ulcerative  action  may  continue,  cavities  be 
created  in  the  manner  already  indicated,  or  communications  be  estab- 
lished between  the  stomach  and  colon,  or  a  fistulous  sinus  be  made 
through  the  walls  of  the  abdomen  externally,  or  the  diaphragm  be  per- 
forated and  the  thoracic  cavity  entered.  When  perforation  takes  place, 
there  being  no  limiting  inflammation,  nor  adhesion  to  adjacent  viscera, 
the  contents  of  the  stomach  are  suddenly  precipitated  into  the  general 
cavity  of  the  abdomen  exciting  general  peritonitis.  Ulcers  situated  on 
the  anterior  wall  of  the  stomach  are  specially  exj)osed  to  this  danger, 
since  in  that  situation  adhesions  can  not  easily  be  formed.  The  larger 
vessels  of  the  stomach  being  deeply  placed,  escape  the  eroding  action 
of  the  ulcer,  unless  the  ulceration  has  proceeded  deeply,  nearly  to  the 
point  of  perforation.  Furthermore,  in  the  process  of  extension  of  the 
ulceration,  the  vessels  resist  longer,  and  become  occluded,  before 
yielding  to  the  erosion.  Now  and  then,  arterial  twigs  are  entered  by 
a  slough,  or  veins  about  the  ulcer,  which  have  become  varicose,  as  is 
frequently  the  case,  are  destroyed  by  a  superficial  ulceration.  Re- 
lapses are  comparatively  frequent.  The  cicatricial  tissue,  being  of  low 
type,  ulcerates  from  slight  causes. 

Changes,  which  have  apparently  some  relation  to  the  morbid  pro- 
cess in  the  stomach,  occur  in  other  organs.  It  is  clear,  however,  that 
certain  diseases  of  the  arterial  system,  as  endocarditis,  endarteritis, 
have  an  immediate  connection,  for  embolism  and  thrombosis  are  im- 
portant factors  in  the  pathogeny  of  ulcer.  In  about  one  half  of  the 
cases,  there  is  coincident  pulmonary  disease,  very  often  tuberculosis. 
It  is  a  popular  notion  that  stomach-ulcers  are  transformed  into  cancer  ; 
it  is  true  that  cancer  sometimes  appears  at  the  site  of  an  old  ulcer. 

Symptoms. — There  are  three  important  symptoms  of  stomach-ulcer 
— pain,  indigestion,  and  vomiting  (hsematemesis).  It  should  be  known 
that  some  very  acute  cases  occur  without  symptoms.  In  apparently  per- 
fect health,  an  individual  has  a  perforation  of  the  walls  of  the  stomach  ; 
an  acute  peritonitis  is  immediately  lighted  up  ;  intense  pain,  vomiting 
of  blood,  and  profound  prostration  occur,  and  death  takes  place  in  a 
few  hours  or  in  a  day  or  two.  The  author  has  met  with  such  a  case. 
More  usually  ulcer  of  the  stomach  is  a  chronic  malady  and  character- 
ized by  the  existence  for  many  months  or  years  of  the  three  symptoms 
mentioned.  Although  the  pain  varies  in  intensity  and  differs  much  in 
different  cases,  yet,  on  the  whole,  there  is  remarkable  correspondence. 
In  the  largest  number  of  cases  the  pain  is  felt  in  front,  in  or  just  below 
the  xiphoid  appendix  ;  or  in  the  left  hypochondrium  in  the  intercostal 
space  between  the  sixth  and  seventh  rib,  occasionally  ;  more  frequent- 
ly above  the  umbilicus,  in  the  neighborhood  of  the  pylorus.  Posteri- 
orly, and  this  position  is  even  more  important,  the  pain  is  felt  in  the 
region  of  the  last  dorsal  or  first  lumbar  vertebra,  or  under  the  angle  of 
the  scapula.     The  pain  in  front  and  behind  seems  to  be  continuous,  as 


ULCER   OF  THE   STOMACH.  3Y 

if  it  passed  directly  tlirough  the  body.  This  is  its  distinctive  charac- 
ter— a  fixed,  gnawing,  burning  pain,  boring  through  from  front  to 
back,  and  occupying  a  space  which  the  finger  may  cover.  More  or 
less  pain  radiates  from  this  central  and  fixed  pain,  and  is  felt  in  the 
chest  behind  the  sternum,  in  the  intercostal  nerves,  in  the  cervico- 
brachial  plexus,  etc.  Very  great  tenderness  is  experienced  on  pressure 
over  the  vertebra  behind  and  the  seat  of  pain  in  front.  Corsets  or  a 
tight  dress  can  not  be  borne,  and,  in  sitting,  the  patient  seeks  a  posi- 
tion more  or  less  bent,  to  avoid  the  pressure  of  internal  organs  against 
the  sore  spot. 

Besides  these,  already  described,  the  patient  suffers  with  attacks  of 
gastralgia,  sometimes  of  extreme  violence,  but  they  do  not  occur  with 
any  regularity.  When  the  gastralgia  comes  on,  the  fixed  pain  is  in- 
creased in  severity,  and  pain  of  extraordinaiy  violence  radiates  through 
the  abdomen  and  chest.  During  these  paroxysms,  the  action  of  the 
heart  becomes  very  feeble,  and  the  vital  forces  much  depressed.  An 
alarming  syncope,  or  general  convulsions,  may  ensue  if  the  patient  pos- 
sess a  highly  sensitive  reflex  organization.  As  the  attacks  are  usually 
due  to  the  presence  of  indigestible  food,  they  cease  when  the  stomach 
is  empty  ;  but  they  also  arise  from  cold,  fatigue,  mental  and  moral 
emotion — to  the  causes,  indeed,  of  neuralgia  elsewhere.  The  pain  of 
stomach-ulcer — the  fixed  pain — is  increased  by  taking  food.  In  a  ma- 
jority of  cases  the  increase  of  pain  is  experienced  as  soon  as  food  enters 
the  stomach  ;  in  a  smaller  proportion  the  exacerbation  occurs  in  from 
fifteen  minutes  to  a  half  hour  ;  in  others,  the  most  severe  suffering 
takes  place  when  food  is  supposed  to  be  passing  through  the  pylorus, 
in  about  three  hours  after  eating.  The  character  of  the  food  influ- 
ences the  production  of  pain — indigestible,  especially  irritating,  arti- 
cles causing  greater  suffering  than  bland  articles.  The  increase  of 
pain  persists  until  the  food  is  rejected  by  vomiting  or  passes  the 
pyloric  orifice.  The  pain  caused  by  the  presence  of  food  in  the  stom- 
ach should  not  be  confounded  with  the  attacks  of  gastralgia,  which 
may  arise  from  hygienic  and  moral  causes  as  well  as  improper  food. 
Some  cases  of  stomach-ulcer  are  free  from  distress  of  any  kind  ;  in 
fact,  they  continue  for  months  and  years  with  no  more  local  disturb- 
ance than  is  produced  by  chronic  gastric  catarrh  ;  but  these  must  be 
regarded  as  exceptional.  Vomiting  is  a  frequent  but  not  an  invari- 
able symptom  ;  in  a  few  instances  it  never  occurs  ;  in  others  it  comes 
on  late  in  the  course  of  the  disease.  The  vomiting  is  preceded  and 
accompanied  by  pain,  but,  when  the  stomach  is  emptied,  the  pain 
ceases.  Occasionally  attacks  of  vomiting  and  pain  occur  when  the 
stomach  is  emf)ty  ;  some  glairy  mucus,  with  or  without  blood,  only, 
coming  up  with  a  good  deal  of  straining,  showing  that  the  disturbance 
of  the  stomach  is  not  due  merely  to  the  presence  of  food.  If  the  vom- 
iting persist,  and  there  be  much  retching,  some  bilious  matter  may 


38  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

finally  be  brought  up.  But  the  great  factor  is  unquestionably  food, 
and  especially  undigested  food  ;  but  more  or  less  gastric  catarrh  is  a 
constant  element  in  cases  of  ulcer  of  the  stomach.  The  time  when  the 
vomiting  occurs  may  indicate  the  position  of  the  ulcer.  If  the  inges- 
tion of  food  is  followed  immediately  by  pain,  the  ulcer  is  probably  in 
the  vicinage  of  the  cardia.  If  situated  in  the  greater  curvature,  there 
may  be  but  little  vomiting,  and  that  will  take  place  in  about  an  hour 
after  food  ;  when  near  the  pylorus,  vomiting  is  an  invariable  symp- 
tom, and  the  pain  is  great,  but  the  pain  and  vomiting  do  not  come  on 
until  two  or  three  hours.  It  must  be  admitted  that  these  statements 
as  to  the  time  of  the  vomiting  and  the  position  of  the  ulcer  are  only 
approximately  correct.  Vomiting  of  blood  is  the  most  characteristic 
single  symptom,  but  is  not  pathognomonic.  It  is  absent  in  about  one 
third  of  the  cases.  Hsematemesis  may  occur  only  at  the  monthly 
period  as  a  vicarious  discharge,  or  merely  as  an  accompaniment  of  the 
regular  flow.  Pain  coming  on  after  eating,  vomiting  of  food  mixed 
with  blood,  and  then  of  blood  only,  is  an  extremely  significant  combi- 
nation of  symptoms.  The  vomited  matter  may  consist  only  of  blood, 
red  or  brownish  red,  when  it  comes  up  immediately  ;  if  retained  for  a 
short  time,  it  appears  in  clots  more  or  less  blackish  if  acted  on  by  the 
stomach-juices.  When  held  in  the  stomach  for  some  time,  and  the 
amount  is  small,  it  may  present  the  well-known  "  coffee-ground  "  ap- 
pearance ;  but  if  the  quantity  is  large,  and  has  been  acted  on  by  the 
gastric  juice,  and  churned  up  by  the  movements  of  the  stomach,  it 
will  then  have  a  brownish-black,  uniformly  granular,  and  homogeneous 
aspect.  As  the  vomiting  usually  occurs  quickly  after  the  blood  is 
jDoured  out,  the  ordinary  and  chai-acteristic  appearance  is  that  of  red- 
dish blood  partly  coagulated.  Coffee-grounds,  blackish  and  brownish- 
black  masses  or  particles,  belong  rather  to  cancer.  The  nutrition  may 
or  may  not  be  impaired  in  gastric  ulcer.  The  small  perforating  ulcer 
is  often  met  with  in  young  girls  of  rather  full  habit  but  lymphatic  in 
type.  The  chronic  ulcer  of  long  standing,  if  small,  may  not  affect  the 
digestion  sufficiently  to  lower  the  body- weight;  but,  if  large,  the  diges- 
tion-space is  so  much  abridged,  that  there  must  be  a  constant  waste, 
which  the  primary  assimilation  is  unable  to  supply.  Much  depends  on 
the  amount  of  loss  by  vomiting,  and  this  is  influenced  somewhat  by  the 
inherent  irritability  of  the  stomach.  The  frequent  recurrence  of  haem- 
orrhage also  seriously  impairs  the  nutrition  and  induces  a  cachectic 
state  and  a  peculiar  tint  of  the  skin,  which  may  be  confounded  with 
the  earthy  hue  of  carcinoma.  The  tongue  may  be  clean,  somewhat 
furred,  red  at  the  tip  and  at  the  edges,  fissured,  but  there  is  no  charac- 
teristic appearance.  As  a  rule,  there  is  obstinate  constipation.  Ameu- 
orrhoea  is  a  frequent  complication,  due  partly  to  the  vicarious  hsemate- 
mesis  and  partly  to  the  jjrofound  anaemia  to  which  some  patients  are 
reduced. 


ULCER   OF   THE   STOMACH.  39 

Course  and  Duration. — The  behavior  of  the  acute  and  perforating 
ulcer  has  been  sufficiently  discussed.  The  chronic  and  common  form 
has  a  very  variable  duration.  Well-authenticated  cases  have  existed 
ten  years — an  example  of  which  the  author  has  had  under  observation. 
From  three  to  five  years  is  a  comparatively  common  period  of  duration. 
The  chief  reasons  for  their  long-continued  existence  are,  their  essen- 
tially chronic  character  and  the  frequent  changes  in  their  condition--^ 
now  increasing,  now  improving,  almost  cicatrized,  then  a  change  in 
the  constitutional  state  of  the  patient,  or  indiscretion  in  food  will  re- 
excite  ulceration  in  tissue  almost  or  entirely  repaired.  At  various 
periods  in  the  course  of  the  chronic  ulcer  there  may  occur  a  chill  fol- 
lowed by  fever,  exquisite  tenderness  of  the  epigastric  and  umbilical 
regions,  nausea,  vomiting,  constipation,  a  quick,  small  pulse,  etc.,  symp- 
toms of  a  local  and  limiting  peritonitis.  '  Some  cases  of  chronic  ulcer 
run  an  entirely  latent  course  ;  that  is,  there  are  no  more  pronounced 
symptoms  than  those  of  dyspepsia. 

Termination. — A  large  proportion  terminate  in  recovery — complete 
cicatrization,  without  any  subsequent  impairment  of  the  functions  of 
the  stomach.  The  cure  may  be  partial ;  there  may  be  adhesions  con- 
tracted to  adjacent  organs,  which  alter  the  shape  and  impair  the  mo- 
tions of  the  stomach  ;  contraction  of  the  pyloric  orifice,  leading  to  dila- 
tation and  gradual  inanition.  The  ulcer  may  cause  death  in  various 
ways  :  there  may  be  a  gradual  failure  from  pain,  vomiting  of  food, 
vomiting  of  blood,  and  by  the  growth  of  lesions  in  other  organs  (car- 
diac disease,  tuberculosis,  etc.).  Death  may  occur  by  haemorrhage — 
according  to  Brinton  five  in  one  hundred  so  terminate.  A  consider- 
able proportion — 13 "4  per  cent. — die  by  perforation  and  consequent 
peritonitis.  This  unfortunate  accident  is  announced  by  a  sudden  and 
great  depression  in  the  powers  of  life,  and  death  by  shock,  or  the 
prompt  development  of  fatal  peritonitis. 

Diagnosis. — Notwithstanding  a  diagnosis  may  be  made  with  great 
certainty  in  cases  presenting  typical  symptoms,  it  may  be  very  difficult 
in  other  cases.  The  doubts  may  occur  between  ulcer  and  chronic 
gastric  catarrh,  gastralgia,  hepatic  colic,  cancer,  and  chlorosis.  In 
chronic  gastric  catarrh  the  pain  after  food  is  much  less,  and,  in  fact, 
in  very  many  cases  the  distress  is  alleviated  by  taking  food  ;  vomiting- 
is  occasional,  and  there  is  no  vomiting  of  blood.  The  paroxysms  of 
gastralgia  may  be  the  same  as  in  ulcer,  but  the  behavior  of  the  two 
diseases,  otherwise,  is  very  different.  Gastralgia  is  in  paroxysms  en- 
tirely, and  between  them  the  patient  suffers  but  little,  and  does  not 
always  have  pain  after  eating,  vomiting,  and  relief  by  the  rejection  of 
food  and  the  vomiting  of  blood.  In  hepatic  colic  the  pain  radiates 
from  the  region  of  the  gall-bladder,  suddenly  terminates  when  the  cal- 
culus reaches  the  intestine,  and  is  followed  by  jaundice.  During  the 
attack,  owing  to  the  congestion  of  the  portal  system,  there  may  be 


4:0  DISEASES  OF  THE  DIGESTIVE   SYSTEM. 

vomiting  of  blood,  but  it  is  never  great  in  amount,  and  all  the  symp- 
toms subside  in  a  few  days,  the  patient  being  free  from  any  disturb- 
ance of  the  stomach  afterward.  In  cancer,  the  age  of  the  subject,  the 
emaciation  and  cachexia,  the  tumor  and  enlarged  lymphatic  glands, 
the  vomiting  of  coffee-ground  and  blackish  and  brownish-black  mate- 
rial, instead  of  the  red  or  brownish-red  blood  in  large  amount  in  ulcer, 
are  the  most  characteristic  differences.  It  is  more  difficult  to  separate 
chlorosis  with  amenorrhoea  from  ulcer  of  the  stomach,  because  these 
subjects  have  the  distress  after  food,  the  vomiting,  and  vicarious  men- 
struation by  the  stomach.  Under  these  circumstances  of  inevitable 
doubt,  it  were  better  to  decide  by  therapeutic  means.  The  case  may 
be  treated  as  one  of  gastric  ulcer  by  an  absolute  low  diet ;  if  it  is  a 
case  of  ulcer,  it  will  improve  under  this  method  ;  if  a  case  of  chlorosis, 
it  will  get  worse — then  a  resort  to  iron  and  mineral  acids  will  bring 
about  a  decided  change  for  the  better. 

Prognosis. — Although  the  cure  of  ulcer  may  be  confidently  expected 
in  favorable  cases,  yet  such  are  the  dangers  from  perforation  and 
haemorrhage  that  the  prognosis  must  be  regarded  as  serious.  When 
tuberculosis  and  endocardial  lesions  exist,  the  gravity  of  the  case  is 
correspondingly  increased. 

Treatment. — The  first  and  most  important  consideration  is  to  give 
the  stomach  rest,  which  is  accomplished  by  reducing  the  food  taken  to 
the  minimum.  An  exclusive  milk-diet  accomplishes  this  object,  while 
at  the  same  time  it  contains  the  necessary  alimentary  principles  for 
the  support  of  the  body.  All  rough,  harsh,  and  coarse  ingesta,  such  as 
oatmeal,  brown-bread,  and  fruits,  irritate  the  surface  of  the  ulcer,  and 
increase  the  existing  ulceration,  and  retard  healing.  Starchy  and  sac- 
charine foods  are  objectionable  because  they  ferment,  producing  acid 
which  is  very  irritating  to  the  ulcerated  surface.  Milk  should  be  given 
systematically — one  gill  (four  ounces)  every  three  hours,  day  and  night, 
during  waking.  If  it  cause  a  sensation  of  heaviness  or  uneasiness, 
nausea  or  vomiting,  the  addition  of  lime-water  will  enable  it  to  be  better 
borne.  The  meat  solution  so  strongly  advocated  by  Leube,  or  that  of 
Valentine,  can  be  substituted  for  milk,  if  the  latter  jjrove  repugnant  to 
the  patient  or  can  not  for  any  reason  be  used.  To  aid  in  supporting  the 
powers  of  life,  rectal  alimentation  may  be  employed.  Foster  proposes 
to  relieve  the  stomach  entirely  for  a  time,  supporting  the  powers  of 
life  by  rectal  alimentation,  since  the  healing  process  is  greatly  pro- 
moted by  giving  the  organ  some  days  of  absolute  rest.  The  discovery 
of  the  utility  of  defibrinated  blood,  as  a  means  of  rectal  alimenta- 
tion, made  by  Dr.  Smith,  of  New  York,  has  added  much  to  our 
resources.  The  method  consists  simply  in  defibrinating  the  blood 
as  soon  as  drawn  at  the  shambles,  and  in  injecting  from  three  to  six 
ounces  morning  and  evening.  If  rectal  alimentation  is  not  em- 
ployed exclusively,  it  should  be  combined  with  the  milk  regimen — 


CARCINOMA  OF  THE   STOMACH.  41 

for,  the  richer  the  condition  of  the  blood,  the  more  rapidly  and  per- 
fectly can  repair  take  place.  As  the  destruction  of  the  mucous 
membrane  was  originally  brought  about  by  the  solvent  action  of 
the  gastric  juice,  and  as  the  irritation  caused  by  this  is  the  chief 
obstacle  to  healing,  it  is  important  to  diminish  the  acidity  and  to 
keep  the  surface  of  the  ulcer  clean.  These  purposes  are  now  ac- 
complished by  mechanical  means,  by  irrigation  of  the  cavity  of  the 
stomach  by  the  siphon  or  the  stomach-pump,  as  the  same  process  is 
employed  in  other  stomach-diseases  ;  but  caution  is  necessary  in  the  use 
of  the  pump,  lest  the  tube  might  cause  a  perforation.  The  same  ob- 
ject may  be  accomplished  by  medicinal  means — by  the  free  use  of  the 
alkaline  mineral  waters.  As  regards  the  strictly  medicinal  remedies,  the 
most  important  is  arsenic  in  small  doses,  one  drop  of  Fowler's  solution 
three  times  a  day.  Next,  named  in  the  order  of  their  relative  impor- 
tance, are,  oxide  and  nitrate  of  silver,  in  half -grain  doses  three  times 
a  day,  and  bismuth  in  fifteen-grain  doses.  If  there  be  much  pain, 
morphia  in  the  hypodermatic  mode  ;  but,  if  the  alimentation  is  proper, 
pain  will  hardly  require  attention.  The  regimen  advised  should  be 
pursued  for  several  weeks,  or  until  such  improvement  is  manifest  as 
to  indicate  that  cicatrization  is  pretty  well  advanced,  when  the  diet 
may  be  very  carefully  enlarged  by  the  addition  of  rice,  soft-boiled 
eggs,  animal  broth,  etc.  ;  but  the  patient  should  be  impressed  with  the 
importance  of  a  simple  dietary  ever  after.  The  accidents  which  arise 
should  be  treated  according  to  their  nature.  If  haemorrhage  occur, 
ice  should  be  applied  to  the  epigastrium,  and  pellets  of  ice  should  be 
swallowed ;  ergotin  should  be  injected  subcutaneously,  and  solution 
of  pernitrate  or  of  chloride  of  iron  should  be  administered  by  the 
stomach.  If  perforation  have  taken  place,  the  most  absolute  rest  must 
be  enjoined  and  the  alimentation  must  be  exclusively  rectal.  The 
remedy  above  all  others  is  morphia  by  the  skin,  maintaining  a  decided 
effect. 

CARCINOMA   OF  THE   STOMACH. 

Etiology. — The  points  of  election  for  the  development  of  cancer  in 
the  intestinal  canal,  named  in  the  order  of  their  relative  frequency,  are 
the  stomach,  the  rectum,  the  caecum,  the  flexures  of  the  colon.  Of  all 
the  organs  of  the  body,  the  stomach  is  most  frequently  the  seat  of 
cancer — more  frequently  than  the  uterus,  which  comes,  strictly,  next. 
As  regards  age,  the  majority  of  cases  occur  at  fifty,  but  the  disease 
may  appear  at  any  time  from  forty-five  to  sixty.  It  is  very  rare  from 
thirty  to  forty.  According  to  some  authorities,  cancer  attacks  the 
male  sex  by  j)reference,  but  careful  investigation  shows  that  this  view 
is  erroneous,  and  that  the  two  sexes  are  about  equally  affected.  The 
well-to-do  classes  are  said  to  be  more  liable  to  the  disease  than  the 


42  DISEASES  OF  THE  DIGESTIVE    SYSTEM. 

poor,  and  the  obese,  hearty  feeders,  rather  than  the  abstemious,  but 
these  are  doubtful  propositions. 

Predisposition  and  heredity  play  an  important  part  in  the  causation 
of  cancer  ;  they  are,  doubtless,  the  most  influential  factors.  The  in- 
herited tendency  may  not  be  traced  sometimes,  when  it  exists,  be- 
cause of  the  behavior  of  the  cancer-germ,  skipping  over  one  or  more 
generations  and  appearing  in  subsequent  ones.  All  other  presumed 
moral  and  dietetic  causes  are  rather  fanciful. 

Patholo^cal  Anatomy. — The  forms  of  cancer  occurring  in  the  stom- 
ach are  the  following  :  scirrhus,  or  fibroid  ;  medullary,  or  encepha- 
loid  ;  and  the  gelatinous,  or  colloid.  As  regards  the  site,  the  points 
of  election  are  in  sixty  per  cent,  at  the  pylorus  ;  in  twenty  per  cent,  at 
the  lesser  curvature  ;  and  in  ten  per  cent,  at  the  cardia.  In  the  pro- 
cess of  growth,  extension  is  more  apt  to  be  vertical  than  transverse  ; 
but,  when  the  growth  is  about  the  cardia  or  the  pylorus,  the  new  for- 
mation takes  an  annular  direction,  causing  stenosis. 

The  initial  changes  in  the  development  of  cancer  of  the  stomach  are 
an  increased  vascularity  and  the  presence  of  numerous  white  blood- 
corpuscles  in  the  cylindrical  epithelium  of  the  gastric  glands — as  in 
ordinary  inflammation — but  the  changes  soon  take  a  special  direction 
and  character.  Rapid  proliferation  of  the  cells  of  the  cylindrical  epi- 
thelium occurs,  and  assumes  a  downward  direction,  penetrating  the 
mucosa,  the  sub-mucosa,  to  the  muscular  layer,  into  which  ultimately 
long,  fibrous  bands  project.  In  the  loose,  submucous  connective  tissue 
the  growth  is  most  rapid,  and  here  the  nodules  form  in  greatest  num- 
bers. The  so-called  cancer-cells — groups  of  proliferating  cylindrical 
epithelial  cells — lie  imbedded  in  a  fibrous  stroma,  made  up  from  the 
connective  tissue  of  the  mucous  membrane.  Within  and  about  the 
stroma  an  infiltration  of  small  cells  appears,  and  out  of  or  within  these 
are  formed  numerous  minute  vessels.  Thus,  in  a  short  time  from  the 
beginning  of  the  process,  all  of  the  anatomical  elements  of  the  mucous 
membrane  are  appropriated  by  the  new  formation.  In  the  course  of 
development  of  scirrhus,  the  connective-tissue  element,  the  fibrous 
stroma,  takes  on  a  ^preponderating  growth  over  the  epithelium  cells 
and  the  small  cell  infiltration,  with  its  newly  formed  vessels.*  It  is  in 
consequence  of  this  preponderance  of  the  connective-tissue  element, 
whether  in  distinct  nodules  or  in  a  dense  annular  mass,  that  it  presents 
such  a  cartilaginous  apj^earance  on  section.  A  large  part  of  the  stom- 
ach may  be  converted  into  a  mass  of  scirrhus,  of  one  or  two  inches  in 

*  Waldeyer,  Virchow's  "Archiv.,"  vol.  xli,  p.  4*70,  and  vol.  Iv,  p.  6*7,  "Die  En- 
twickelung  dei-  Carcinome."  Also  Forster,  "Lehrbuch  dei"  path.  Anat.,"  pp.  110-115,  by 
Siebert,  .Jena,  1873.  Rindfleisch,  "  Text-Book  of  Pathological  Histology,"  Lindsay  &  Blak- 
iston,  18Y2,  p.  375,  confirms  Waldeyer's  account  of  the  origin  of  cancer  in  the  mucosa. 
See  also  Rokitansky,  and  especially  the  great  work  of  Cruveilhier,  "Traite  d' Ana- 
tomic Pathologique,"  where  colloid  will  be  found  admirably  delineated. 


CARCINOMA   OF   THE   STOMACH.  4.3 

thickness,  with,  nodules  and  protuberances  of  greater  thickness  pro- 
jecting into  the  cavity.  A  dense  mass,  of  half  to  an  inch  in  thick- 
ness, much  less  nodular,  may  surround  the  pylorus  or  the  cardia,  leav- 
ing a  considerable  part  of  the  mucous  membrane  of  the  stomach  free 
from  disease.  No  part  of  the  mucosa  exists  after  the  cancer  is  devel- 
oped ;  hence  the  internal  surface  of  the  stomach  at  that  point  is  the 
surface  of  the  cancer  only,  which  is  usually  in  an  ulcerating  state. 

Medullary  cancer,  or  encephaloid,  differs  from  scirrhus  in  the  less 
gi'owth  of  the  fibi'ous  stroma,  and  in  a  much,  more  luxuriant  prolifera- 
tion of  the  small  cells  and  their  associated  vessels.  Hence  this  form 
of  the  disease  is  softer,  more  vascular,  and  possessed  of  a  greater 
power  of  rapid  growth.  Some  parts  of  this  form  of  cancer  may,  and 
usually  do,  retain  the  characteristic  fibrous  stroma  of  scirrhus.  The 
internal  or  gastric  surface  usually  consists  of  projecting  nodules  of 
softened  cancer  elements,  which  are  easily  detached  and  bleed  readily. 
The  ulceration  which  occurs  in  the  exposed  surface  within  the  cavity 
of  the  stomach  really  consists  in  a  process  of  fatty  degeneration,  the 
disintegration  being  produced  by  the  solvent  action  of  the  gastric 
juice  and  the  mechanical  action  of  the  food. 

Colloid  cancer  differs  from  the  other  varieties  in  that  a  gelatini- 
form  degeneration  of  the  cancer-cells  takes  place,  giving  the  peculiar 
colloid  appearance.  The  distention  of  the  alveoli  by  this  material  di- 
lates them  so  that  they  are  larger  than  in  other  forms.  This  variety 
differs  from  the  others  also  in  that  it  is  more  widely  diffused  through 
the  mucous  membrane,  and  through  neighboring  organs,  and  is  slower 
and  longer  in  growth.     It  is  also  less  common. 

Cancer,  like  ulcer,  by  setting  up  local  peritonitis  leads  to  the  for- 
mation of  adhesions,  which  affect  the  shape,  position,  and  motions  of 
the  stomach.  Adhesions  may  fix  the  pylorus  in  or  about  its  true  posi- 
tion, but,  when  unattached,  the  weight  of  the  cancerous  mass  may 
drag  it  down,  even  as  low  as  the  hypochondrium,  and  thus  constitute 
a  movable  tumor.  When  the  annular  deposits  form  at  the  pylorus,  a 
stenosis  of  the  orifice  and  dilatation  of  the  cavity  are  results.  When 
the  same  formation  occurs  at  the  cardia,  the  stomach  very  much  con- 
tracts, and  the  Ofsophagus  immediately  above  dilates.  In  the  vicinage 
of  the  connective-tissue  bands,  which  stretch  out  through  the  subjacent 
elements,  especially  the  muscular,  considerable  hypertrophy  of  these 
muscular  elements  at  first  results,  but  atrophy,  from  pressure  of  the 
newly  formed  connective  tissue,  finally  occurs,*  Those  portions  of 
the  mucous  membrane  uninvaded  by  the  cancer  elements  suffer  chronic 
catarrh,  in  consequence,  doubtless,  of  the  continued  hyperemia.  That 
from  such  a  state  of  the  mucous  membrane  cancer  may  develop,  is  a 
popular  notion,  not  supported  by  any  scientific  data.     It  is  true  that 

*  Luton,  "  Cancer  de  I'Estomac,"  "Nouveau  Diet,  de  Med.,"  Paris,  1871. 


44  DISEASES   OF  THE   DIGESTIVE   SYSTEM. 

hypersemia  of  the  cells  of  the  cylindrical  epithelium  ds  apparently  the 
starting-point  of  the  development  of  cancer,  but  this  hypersemia  is 
due  to  some  peculiar  irritation  in  the  tissue.  Cancer  has  developed 
from  an  old  ulcer  in  some  rare  instances,  but  some  remnant  of  gland- 
tissue  must  have  remained. 

Cancer  of  the  stomach  is  usually  primary,  and  in  most  of  the  cases 
is  confined  to  that  organ.  It  is  rare,  indeed,  for  the  stomach  to  be 
secondarily  affected  ;  but  the  author  has  seen  a  case  in  which  cancer 
of  the  gall-bladder  was  followed  by  secondary  deposits  in  the  pylorus 
— an  altogether  unique  case.  In  less  than  half  the  cases,  cancer  in- 
volves other  organs  as  well  as  the  stomach,  and  notably  the  liver, 
which  is  affected  in  about  one  fourth.  Secondary  deposits  in  the 
liver  less  often  occur  when  the  cardia  is  involved  than  when  the  lesser 
curvature  and  the  pylorus  are  the  sites  of  cancer. 

The  principal  complications  of  cancer  of  the  stomach  are  fatty 
heart,  thromboses,  pneumonia,  tuberculosis,  etc. 

Symptoms. — In  a  few  rare  cases  cancer  has  proceeded  from  its  in- 
ception to  its  termination  in  the  death  of  the  patient  without  causing 
any  distinctive  symptoms.  These  are  examples  of  cancerous  infiltra- 
tion of  the  mucous  membrane  in  the  greater  curvature,  the  orifices 
being  unaffected.  In  the  first  stage,  before  a  tumor  can  be  detected 
or  the  cachexia  is  evident,  the  symptoms  present  are  those  of  a  dys- 
pepsia, which  gradually  assumes  a  more  aggravated  character.  There 
is  a  good  deal  of  pain  from  an  early  period,  felt  in  the  epigastrium 
usually,  and  increased  by  pressure,  by  food,  and  is  also  felt  poste- 
riorly. The  pain  is  nearly  constant,  and,  although  at  times  more 
severe,  there  are  not,  as  a  rule,  those  violent  paroxysmal  attacks  so 
often  found  in  ulcer.  The  pain  is  acute,  often  burning,  sometimes 
lancinating,  but  by  no  means  invariably  so  ;  again,  it  is  a  sense  of 
soreness  and  not  severe  pain  ;  rarely  it  is  entirely  absent,  according 
to  Brinton,  in  eight  per  cent.* 

The  disorders  of  digestion  increase  with  the  duration  of  the  case  : 
the  appetite  declines  ;  distress  after  eating  becomes  greater ;  then 
attacks  of  acidity  and  pyrosis,  with  regurgitation  of  an  acrid,  acid 
liquid,  come  on.  Emaciation  and  loss  of  weight  proceed  at  a  uniform 
ratio.  If  annular  deposits  have  been  occurring  at  the  cardia,  the  pa- 
tient early  becomes  conscious  of  a  difficulty  in  getting  food  into  the 
stomach,  but  he  almost  invariably  refers  the  obstruction  to  a  point 
higher  up.  As  the  case  advances,  the  alimentary  substances  pass 
slowly  down  to  the  cardia,  where  they  are  arrested  for  a  minute  or 
more,  some  portions  trickling  through  into  the  stomach,  the  rest  slowly 
returned  by  regurgitation,  with  a  distinct  gurgling  noise.     Consider- 

*  "  Medico-Chirurgical  Review,"  vol.  xx,  p.  479,  Also  Brinton  on  "  Diseases  of  the 
Stomach." 


CARCINOMA   OF   THE   STOMACH.  45 

able  pain  is  experienced — a  burning  pain  usually — when  the  substances 
swallowed  reach  the  cardia,  and  as  they  pass  through  it  into  the 
cavity.  This  passage  through  the  narrowed  orifice  is,  as  a  rule,  dis- 
tinctly recognized  and  accurately  described.  When  the  liquid  or  solid 
is  disposed  of,  either  by  regurgitation  or  by  entrance  into  the  stom- 
ach, there  is  a  feeling  of  relief,  and  the  stomach  digestion  goes  on  with 
the  ordinary  facility.  In  cancer  of  the  cardia,  but  a  small  portion  of 
the  mucous  membrane  is  destroyed — the  deposits  being  annular — and, 
as  death  takes  place  earlier  by  inanition  than  in  any  other  form,  there 
is  not  much  interference  with  digestion,  and  these  unfortunates  suffer 
horribly  from  hunger.  The  epigastrium  contracts  and  is  drawn  in 
toward  the  spine,  owing  partly  to  the  exceeding  general  emaciation, 
and  partly  to  the  extreme  contraction  of  the  stomach. 

In  the  other  forms  of  cancer,  instead  of  arrest  at  the  cardia,  the 
patient  feels  no  distress  until  the  alimentary  materials  reach  the  stom- 
ach, when  nausea  and  other  distresses  begin.  Vomiting  is  one  of  the 
most  constant  symptoms,  occurring  in  three  fourths  of  the  cases.  At 
first  the  patient  brings  up  in  the  morning,  with  a  good  deal  of  strain- 
ing, some  tough,  glairy  mucus,  and,  it  may  be,  a  little  bilious  matter. 
Presently  the  vomiting  comes  on  after  eating ;  if  the  cancer  is  situ- 
ated just  below  the  cardiac  orifice,  and  does  not  constrict  it,  pain,  nau- 
sea, and  vomiting,  begin  almost  immediately  after  the  food  is  swal- 
lowed. If  the  posterior  wall  is  affected  only,  vomiting  may  not  occur 
until  late  in  the  disease,  and  then  may  not  be  a  very  pronounced 
symptom.  When  the  pylorus  is  affected,  vomiting  is  a  pretty  nearly 
constant  symptom,  but  it  does  not  occur  until  some  time  after  the 
food  has  reached  the  stomach — as  a  rule,  not  until  two  or  three  hours 
have  elapsed.  The  vomited  matters  consist  at  first  of  the  food  in 
various  stages  of  solution,  then  of  mucus,  containing  sarcina  and  other 
minute  organisms,  and  when  the  case  is  pretty  well  advanced  there 
appear  small  brownish  or  brownish-black  or  chocolate-colored  masses, 
of  small  size  usually,  which  consist  of  decomposed  blood.  Vomiting 
ultimately  occurs  without  the  presence  of  food  :  it  is  then  the  form 
of  vomiting  entitled  vomiting  of  irritation.  Haematemesis  is  a  fre- 
quent but  not  a  constant  symptom,  occurring  in  somewhat  less  than 
half  the  cases  (forty-two  in  one  hundred,  according  to  Brinton).  If, 
however,  the  vomited  matters  were  carefully  searched  for  altered 
blood,  it  would  probably  be  found  present  in  nearly  all  cases.  If  the 
spectroscope  were  employed  to  examine  all  suspicious-looking  parti- 
cles, the  absorption-bands  between  C  and  D,  characteristic  of  hsema- 
tin,  would  be  often  seen.  Vomiting  of  blood  in  large  quantity,  as 
occurs  in  ulcer,  is  quite  exceptional  in  cancer.  Usually  the  blood  is 
derived  from  small  capillaries,  but  now  and  then  sloughing  takes  place, 
and  a  vessel  of  considerable  size  is  opened.  The  author  has  observed 
in  some   cases  an  enormous  quantity  of  chocolate-colored,  homoge- 


46  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

neons,  granular  material,  discharged  both  hy  vomit  and  by  stool,  in 
cases  of  cancer  at  the  pylorus.  The  condition  of  the  bowel  is  that  of 
torpor,  but  toward  the  end  ichorous  matter  passing  down  the  intestine 
excites  diarrhoea. 

In  one  third  of  the  cases  observed  by  the  author,  salivation  (not 
mercurial)  was  a  symptom,  and  was  either  constantly  or  periodically 
present.  The  saliva  had  the  ordinary  appearance.  The  tongue  is  red 
at  the  tip  and  pointed,  and  is  usually  glazed. 

The  cachexia  induced  by  cancer  is  characteristic.  With  the  prog- 
ress of  emaciation,  decline  of  strength  is  to  be  expected,  but  the  sub- 
jects of  the  cancerous  cachexia  have  an  extraordinary  sense  of  fatigue, 
which  is  felt  when  no  exertion  is  made.  The  action  of  the  heart  is 
feeble,  the  pulse  small,  weak,  and  quick  ;  the  respiration  somewhat 
hurried.  The  least  exertion  increases  the  number  of  the  heart-beats 
and  the  respiration  movements.  The  skin  is  thin,  dry,  harsh,  and  in- 
elastic. The  complexion  is  pallid,  earthy,  and  bronzed,  combined — a 
fawn  color — and  is  strongly  suggestive  of  the  malady.  Toward  the 
end,  oedema  of  the  ankles  appears — a  mechanical  result  of  the  throm- 
boses.    The  cachexia,  though  it  may  be  late,  never  fails  to  come  on. 

A  tumor  is  found  in  the  proportion  of  eighty  to  one  hundred  cases. 
In  some  situations  the  tumors  can  not  be  felt,  as  when  at  the  cardia,  or 
in  the  lesser  curvature,  for  here  they  are  covered  in  by  the  left  lobe  of 
the  liver.  In  other  situations  they  may  usually  be  detected  by  palpa- 
tion— suitable  attention  being  given  to  all  the  sources  of  error.  The 
variety  of  cancer  does  not  necessarily  affect  the  question  of  a  tumor  ; 
but  a  colloid  growth  may  be  diffused  through  the  walls  of  the  stomach, 
giving  to  the  sense  of  touch  the  impression  of  thickening,  and  not  of  a 
defined  tumor.  On  palpation,  the  tumor,  if  it  exist,  is  felt  to  be  hard, 
somewhat  irregular,  and  nodular,  if  scirrhus,  but  softer  and  more  elas- 
tic, yet  well  defined,  if  encephaloid  or  colloid.  Even  when  in  a  position 
to  be  felt,  it  may  elude  search  by  reason  of  distention  of  the  stomach, 
or  of  adhesions  which  may  change  the  shape  and  position  of  the  organ, 
or  the  presence  of  fluid  in  the  peritoneal  cavity — a  result  of  the  pres- 
sure of  secondary  deposits  in  the  liver.  Tumor  of  the  liver,  of  the 
pancreas,  movable  kidney,  aneurism,  may  be  confounded  with  tumor 
of  the  stomach,  and  must  be  kept  in  view  when  making  a  diagnosis  by 
exclusion.  The  relation  of  the  tumor  to  the  movements  of  the  dia- 
phragm should  be  noted  ;  for  a  tumor  of  the  stomach  does  not  descend 
when  the  lung  is  inflated  with  air.  When  the  pylorus  remains  free  the 
weight  of  the  neoplasm  causes  it  to  fall  dowm,  sometimes  as  low  as  the 
hypochondrium,  and  it  continues  movable.  Tumors  of  the  liver  and 
spleen  descend  on  full  insjjiration,  but  the  pyloric  tumor  Avhen  adherent 
retains  its  position,  and  when  movable  is  not  influenced  by  the  respira- 
tory movements.  When  a  scirrhus  lies  upon  the  aorta,  a  pulsation 
is  communicated  to  it,  but  it  is  not  an  expansile  pulsation,  and  there 


CARCINOMA   OF   THE   STOMACH.  47 

are  none  of  the  other  signs  of  aneurism,  yet  mistakes  of  diagnosis  are 
not  infrequent. 

Like  ulcer,  cancer  may  result  in  perforation  and  general  peritonitis  ; 
in  the  formation  of  fistulous  communications  with  the  walls  of  the 
abdomen,  externally,  with  the  transverse  colon,  when  there  will  be 
stercoraceous  vomiting  ;  with  the  thoracic  cavity  ;  but  these  are  com- 
paratively rare  complications.  Occasionally  a  large  vessel  is  laid  open, 
and  death  ensues  from  sudden  and  large  haemorrhage.  In  accordance 
with  its  nature,  cancer  tends  to  spread  to  contiguous  parts,  by  reason 
of  immediate  vascular  communication.  The  cancer  elements  are  much 
more  frequently  deposited  in  the  liver  than  in  any  other  organ.  As- 
cites, icterus,  thrombosis  of  the  portal  vein,  etc.,  are  the  most  important 
results  of  the  implication  of  the  liver.  Extension  of  the  disease  also 
occurs  by  the  lymphatics,  and  large  nodular  masses  of  degenerating 
mesentei'ic  glands  may  be  felt  through  the  thin  parietes  of  the  abdo- 
men during  the  life  of  the  patient.  The  cervical  lymphatics,  just  above 
the  clavicle,  also  sometimes  enlarge,  and  afford  valuable  indications  of 
the  nature  of  the  malady,  even  early  in  the  course  of  the  disease. 

Tuberculosis  of  the  lungs  is  a  frequent  complication  of  cancer  of 
the  stomach. 

Course  and  Duration. — Cancer  of  the  stomach  is  an  essentially 
chronic  disease.  The  average  duration,  according  to  Brinton,  is  one 
year  ;  but  the  cases  differ  in  duration  according  to  the  anatomical  site. 
Named  in  the  order  of  their  fatality,  they  stand  as  follows  :  cancer  of 
the  cardia,  of  the  pylorus,  of  the  lesser  curvature,  of  the  greater  curva- 
ture.    The  maximum  duration  is  three  years. 

Diagnosis. — The  differentiation  is  to  be  made  between  chronic  gas- 
tric catarrh,  chronic  ulcer,  and  carcinoma.  In  the  eai'ly  stages  of  ulcer 
and  cancer  it  may  be  impossible  to  separate  them  from  chronic  gastric 
catarrh ;  but  as  these  cases  progress  the  points  of  difference  become 
distinct.  The  following  considerations  will  enable  a  correct  differentia- 
tion to  be  arrived  at  :  chronic  gastritis  may  occur  at  any  age  ;  there 
is  rarely  any  severe  pain,  and  it  is  diffused  over  the  whole  organ  ; 
vomiting  is  only  occasional,  and  then  of  alimentary  matters,  as  a  rule  ; 
there  is  no  important  variation  in  the  body-weight,  and  no  progressive 
emaciation.  In  ulcer,  the  pain  is  severe,  localized  to  a  small  point  in 
front  and  behind  ;  there  is  much  vomiting  and  haematemesis,  the  blood 
coming  up  in  considerable  quantity,  little  or  not  at  all  altered.  The 
subject  of  cancer  is  well  advanced  in  life  (from  forty  to  sixty)  ;  the 
pain  has  a  lancinating  character,  and  is  felt  in  one  place  which  is  the 
same  for  each  case,  but  differs  in  different  cases  ;  there  is  vomiting, 
especially  vomiting  of  chocolate  or  coffee-ground  masses  of  decomposed 
blood  ;  above  all,  the  presence  of  a  tumor. 

Treatment. — Although  cancer  of  the  stomach  is  incurable,  much 
may  be  done  by  treatment  to  render  the  patient's  decline  tolerable. 


48  DISEASES   or  THE  DIGESTIVE  SYSTEM. 

The  first  and  most  important  point  is  to  regulate  the  diet.  By  the 
withdrawal  of  solid  food,  and  the  substitution  of  milk  alone,  or  milk 
and  beef -juice,  the  greatest  relief  is  afforded,  and  for  a  time  there  may 
be  a  gain  in  weight,  but  of  course  this  is  not  long  maintained.  If  the 
diet  is  restricted  to  the  articles  mentioned,  it  should  be  supplemented 
by  that  important  means  of  rectal  alimentation,  the  injection  of  defibri- 
nated  blood.  The  burning  pain  is  much  diminished  by  washing  out 
the  stomach  oiice  a  day  with  the  stomach-pump,  especially  in  dilatation 
from  stenosis  of  the  pylorus.  By  removing  acrid  and  acid  matters  in 
this  way,  much  straining  efforts  at  vomiting  will  be  saved. 

Of  all  the  remedial  measures  proposed  there  is  no  prescription 
which  is  so  generally  useful  in  these  cases  as  equal  parts  of  pure  car- 
bolic acid  and  tincture  of  iodine,  of  which  one  or  two  drops  may  be 
administered  in  water  three  times  a  day.  For  the  vomiting  only,  a 
solution  in  cherry -laurel  water  of  carbolic  acid,  or  a  combination  of 
carbolic  acid  with  bismuth  in  an  emulsion,  will  be  found  effective. 
Nitro-glycerine,  benzine,  and  bisulphide  of  carbon  have  been  used,  with 
advantage,  to  allay  nausea  and  vomiting.  The  most  effective  means 
to  allay  pain  is  the  hypodermatic  injection  of  morphia.  The  stomachal 
administration  of  the  same  agent  is  inefficient,  owing  to  the  diminished 
absorption  power  of  the  organ.  Laudanum  by  enema,  morphia  in  the 
form  of  suppository,  or  the  endermic  use  of  morphia,  are  preferable  to 
the  stomach  administration.  Great  care  is  necessary  in  the  prescription 
of  anodynes,  for  the  need  grows  rapidly,  and  the  consumption  becomes 
enormous,  reducing  the  patient  to  a  mental  and  moral  weakness  dread- 
ful to  contemplate. 

Arsenic,  in  the  form  of  Fowler's  solution,  one  or  two  drops,  three 
times  a  day,  has  considerable  power  to  allay  pain,  and  is  not  without 
influence  in  retarding  the  growth  of  epithelial  cancer.  As  respects  the 
power  to  relieve  pain,  the  physiological  basis  for  its  employment  is  the 
action  of  arsenic,  in  toxic  doses,  on  the  nervous  system  of  animal  life. 
It  has  been  repeatedly  observed  that  sometimes,  in  large  doses,  no 
vomiting  was  produced,  but  coma  and  insensibility  followed.  A  great 
many  facts  have  now  been  accumulated,  proving  that  cancer  of  epithe- 
lial origin  may  be  greatly  retarded  in  its  growth  by  the  persistent  use 
of  moderate  doses—- two  drops  of  Fowler's  solutibn  ter  in  die. 

The  author's  considerable  experience  in  the  treatment  of  carcinoma 
of  the  stomach  warrants  the  statement  that  the  best  results  are  obtained 
by  the  persistent  use  of  carbolic  acid  and  iodine,  in  the  form  advised 
above,  and  of  arsenic,  in  the  form  of  Fowler's  solution.  It  may  not 
be  needless  to  observe  that  these  agents  should  not  be  given  in  one 
prescription — the  carbolic  acid  and  iodine  together,  the  Fowler's  solu- 
tion at  another  time. 


VOMITING   OF   BLOOD.  49 

HffiMATEMESIS— HEMORRHAGE     OF     THE     STOMACH— VOMIT- 

ING   OF   BLOOD. 

Definition. — Ha3matemesis  and  vomiting  of  blood  do  not  adequate- 
ly name  tlie  malady,  for  blood  may  be  swallowed  and  then  vomited. 
Haemorrhage  of  the  stomach  is  the  correct  term. 

Causes. — Rupture  of  a  stomach  blood-vessel  is  the  essential  condi- 
tion of  stomachal  haemorrhage,  notwithstanding,  under  some  circum- 
stances, diapedesis  of  the  corpuscular  elements  does  occur.  Sufficient 
blood  must  escape  to  excite  nausea  and  vomiting.  During  an  inflam- 
matory stasis,  considerable  blood  may  escape  from  ruptured  capillaries, 
but  usually  haemorrhage  is  due  to  the  giving  way  of  vessels  of  some 
size  ;  diapedesis,  certainly,  is  quite  inadequate  to  bring  about  the  es- 
cape of  much  blood.  There  may  be  disease  of  the  tunics  of  the  blood- 
vessels sufficient  to  cause  them  to  give  way  on  slight  increase  of  the 
blood-pressure.  Furthermore,  long-continued  abnormal  pressure  will 
induce  slow  changes,  without  invoking  other  causes  to  account  for 
their  yielding  should  the  pressure  suddenly  become  greater.  In  this 
way  may  we  explain  the  occurrence  of  gastric  haemorrhage  in  cirrho- 
sis, acute  yellow  atrophy  of  the  liver,  yellow  fever.  Certain  lesions, 
acting  mechanically  on  the  portal  vein,  bring  about  the  same  results — 
for  example,  an  aneurism  of  the  hepatic  artery,  a  large  calculus,  or 
tumors  in  the  neighborhood  of  the  portal  vein.  Any  obstruction  of 
the  portal  vein  may  be  the  cause  of  blocking  by  a  thrombus  of  a  ves- 
sel returning  blood  from  a  certain  part  of  the  mucous  membrane — the 
effect  of  this  being  the  production  of  one  or  a  number  of  superficial 
ulcers.  Severe  and  protracted  haemorrhage  may  proceed  from  such 
erosions.  Still  more  remotely  is  the  occurrence  of  gastric  haemorrhage, 
caused  by  increased  pressure  in  the  portal  system  due  to  obstructive 
troubles  of  the  lungs  and  heart.  The  haemorrhagic  diathesis  may 
manifest  itself  in  haemorrhage  from  the  gastric  mucous  membrane. 
Arrest  of  an  haemorrhoidal  discharge,  which  has  continued  for  a  long 
time,  is  supposed,  by  a  sudden  increase  in  the  blood-pressure  within 
the  portal  system,  to  be  a  cause  of  haemorrhage  of  the  stomach. 

According  to  the  statistics  of  Handheld  Jones,  in  seventy-two 
cases  of  haematemesis  there  were  fifty-three  females  to  nineteen  males 
— showing  a  great  preponderance  in  the  female  sex.  As  regards  age, 
from  twenty  to  forty  there  were  nine  males  and  thirty-six  females, 
and  after  forty,  eight  males  and  fourteen  females.  These  facts  indi- 
cate that  vicarious  menstruation  through  the  stomach  must  be  rela- 
tively frequent.  As  in  forty  the  existence  of  ulcers  seemed  probable, 
it  is  rendered  pretty  certain,  by  these  figures,  that  ulcer  is  the  most 
common  cause  of  stomach  haemorrhage.* 

*  "  Medico-Chirurgical  Transactions,"  vol.  xliii,  p.  353. 


50  ■  DISEASES   OF   THE   DIGESTIVE  SYSTEM. 

Pathological  Anatomy. — More  or  less  coagulated  blood,  acted  on 
by  the  acids  of  the  gastric  juice  to  a  varying  extent,  is  found  in  the 
stomach.  It  is  often  impossible  to  discover  the  source  of  the  haemor- 
rhage, unless  the  hsemorrhagic  erosions,  already  alluded  to,  have 
formed.  They  are  usually  situated  in  the  neighborhood  of  the  pylo- 
rus. When  a  large  vessel  has  given  way,  the  rent  can  usually  be 
found  with  a  coagulum  in  it. 

Symptoms. — When  a  haemorrhage  occurs  sufficient  in  amount  to 
produce  definite  symptoms,  the  patient  experiences  a  sensation  of 
warmth  in  the  stomach,  while  the  periphery  is  cool  or  cold  ;  distention, 
nausea,  faintness.  If  the  haemorrhage  is  large,  coming  suddenly  from 
a  vessel  of  considerable  size,  without  any  apparent  cause,  the  patient 
turns  sick,  faint,  pallid,  and  cold,  the  stomach  is  distended,  and  then 
vomiting  sets  in,  the  blood  rushing  up  in  a  full  stream  through  the 
mouth  and  nose,  or  if  less  in  amount  it  comes  uj)  by  successive  acts  of 
vomiting.  The  faintness  usually  increases  at  the  sight  of  blood,  and 
only  passes  off  on  the  cessation  of  the  bleeding.  In  rare  instances  a 
large  haemorrhage  occurs,  the  stomach  is  fully  distended  and  returns  a 
perfectly  flat  percussion-note,  the  patient  becomes  pale  and  cold  and 
faint,  or  he  actually  does  faint  and  is  convulsed,  without  any  vomit- 
ing, the  blood  subsequently  passing  off  by  stool.  A  patient  enfeebled 
by  disease  may  be  suddenly  carried  off  by  a  haemorrhage  in  the  stom- 
ach without  vomiting.  It  not  unfrequently  happens  that,  when  the 
blood  comes  up  with  a  sudden  gush,  some  is  carried  into  the  larynx, 
where  it  excites  coughing,  and  hence  may  appear  to  be  coughed  up. 
This  fact  leads  to  erroneous  interj^retation  of  the  nature  of  the  case, 
and  confusion  as  to  the  source  of  the  haemorrhage.  The  appearance 
of  the  blood  is  different  according  to  the  time  it  has  been  acted  on  by 
the  gastric  juice.  If  it  comes  up  at  once  in  large  quantities,  it  is  part- 
ly fluid  and  partly  coagulated,  like  ordinary  blood  ;  but,  if  it  has  been 
retained,  it  has  a  blackish,  or  brownish-black,  or  chocolate  appearance, 
and  is  then  rather  granular  in  structure.  If  but  little  blood  has  es- 
caped and  slowly,  it  presents  the  "  coffee-ground "  appearance.  The 
gastric  juice  decomiDoses  the  haemoglobin  and  sets  free  the  haematin, 
which  gives  the  color  to  the  vomited  matters.  In  concealed  haemor- 
rhage of  the  stomach,  the  blood  passing  into  the  intestines,  and  in  in- 
testinal haemorrhage,  the  same  phenomena  ensue  :  there  occur  sudden 
distention  of  the  abdomen  and  colic-like  pains,  faintness  or  actual 
fainting  with  its  attendant  symptoms,  if  the  loss  of  blood  be  large, 
and  the  stools  of  tarry-like  material,  altered  blood,  at  first  mixed  with 
ordinary  faeces,  and  then  consisting  of  the  decomposed  blood  only.  As 
narrated  in  the  previous  article,  the  author  has  observed  chocolate- 
colored  material  in  large  amount  discharged  by  stool.  It  assumes 
this  appearance  when  acted  on  by  alkaline  fluids,  after  the  effect  of 
acids.     If  this  be  correct,  Ave  have  a  means  of  determining  whether 


VOMITING   OF  BLOOD.  51 

any  given  discharge  of  blood  originated  in  the  stomach  or  intestine. 
Blood  so  colored  may  be  vomited,  but  it  comes  up  after  the  stomach 
is  emptied,  and  is  forced  by  the  act  of  vomiting  from  the  duodenum, 
A  very  singular  result  of  stomach  haemorrhage  is  amaurosis,  first  ob- 
served by  Graefe,  then  Fikentscher,  and  afterward  by  Hutchinson. 
No  explanation  that  has  been  offered  satisfactorily  explains  the  oc- 
currence of  double,  incurable  amaurosis  after  haemorrhage  from  the 
stomach. 

Course,  Duration,  and  Termination. — Occasionally  vomiting  of  blood 
is  fatal,  as  when  an  aneurism  ruptures  into  the  stomach.  Although 
the  patient  may  be  faint,  cold,  and  convulsed,  yet  haemorrhage  of  the 
stomach  is  rarely  fatal,  and  the  patient  slowly  emerges  from  the  con- 
dition of  anaemia.  The  pain  of  ulcer  and  cancer  is  often  much  re- 
lieved by  vomiting  blood  ;  but  the  case  of  idcer  may  be  made  much 
more  serious  by  it  in  all  other  respects.  Haemorrhage  due  to  cirrhosis 
of  the  liver  far  advanced  may  be  difficult  or  impossible  to  control, 
and  may  add  materially  to  the  dangers  of  the  case,  or  may  cause 
death  by  exhaustion. 

Diagnosis. — The  juices  of  colored  fruits  (of  black  raspberries,  for 
example)  may  be  mistaken  for  blood,  especially  when  vomited  in  the 
night.  The  author  has  encountered  several  cases  of  this  kind.  The 
microscope  or  the  spectroscope  may  be  invoked  to  decide.  Much 
greater  difficulty  must  exist  in  determining  the  source  of  the  blood, 
whether  swallowed  and  vomited,  or  derived  from  the  stomach  or  lungs. 
An  examination  of  the  nares  will  usually  demonstrate  the  origin  of  the 
bleeding,  if  the  blood  proceeds  from  any  part  of  the  nasal  mucous 
membrane. 

Blood  from  the  lungs  has  an  alkaline  reaction,  is  aerated,  a  bright 
red,  and  may  contain  mucus  or  pus.  Blood  from  the  stomach  is  acid 
in  reaction  ;  when  acted  on  by  the  gastric  juice,  is  blackish,  brownish- 
black,  or  chocolate  color,  and  is  not  aerated,  and  may  be  mixed  with 
food.  The  act  of  vomiting  brings  up  the  blood  from  the  stomach,  of 
coughing  from  the  lungs  (coughing  may  attend  vomiting  of  blood,  and 
vomiting — the  patient  swallowing  blood  coming  from  the  lungs — may 
attend  pulmonary  haemorrhage).  The  previous  history  of  pulmonary 
disease  and  the  existence  of  moist  rales  at  the  time  of  the  haemorrhage 
indicate  the  limgs  to  be  the  seat  of  the  haemorrhage,  and  the  absence 
of  all  the  physical  evidences  of  fullness  of  the  stomach  negatives  the 
idea  of  stomachal  haemorrhage.  The  attack  begins  in  the  lungs,  by  a 
sense  of  heat  under  the  sternum,  by  a  soreness  in  some  locality,  and 
by  a  sense  of  constriction  of  the  chest ;  in  the  stomach,  by  a  sense  of 
fullness  and  actual  distention  of  the  stomach,  followed  by  nausea. 
After  the  attack  of  pulmonary  haemorrhage  the  patient  experiences 
soreness  at  the  seat  of  the  haemorrhage  ;  there  is  more  or  less  elevation 
of  temperature,  often  a  pneumonia  or  bronchitis  of  small  extent ;  moist 


52     •  DISEASES   or   THE   DIGESTIVE   SYSTEM. 

rales,  and  the  expectoration  for  several  days  of  small,  brownish-bloody 
sputa.  After  the  heematemesis,  only  the  depression  and  ansemia  are 
present  except  stools  of  altered  blood,  which  are  usual. 

Treatment. — The  haemorrhage,  which  is  a  vicarious  menstruation, 
is  relieved  by  diverting  the  flux  to  the  uterus,  its  natural  outlet.  This 
is  best  accomplished  by  the  use  of  the  appropriate  emmenagogues  dur- 
ing the  interval,  of  hot  sitz-baths  and  hot  vaginal  douches,  at  the  time 
of  the  expected  flow.  In  the  case  of  married  women,  leeches  may  be 
applied  to  the  cervix  uteri  at  the  time  of  the  menstrual  molimen. 
When  due  to  arrested  hsemorrhoidal  discharge,  leeches  should  be  ap- 
plied to  the  anus,  and  aloes  be  administered. 

When  an  impoverished  condition  of  the  blood  exists,  or  when  the 
so-called  hsemorrhagic  diathesis  is  the  cause  of  haemorrhage,  effort 
must  be  directed  to  improve  the  composition  of  the  blood,  and  to  ele- 
vate the  tonus  of  the  vessels.  When  the  haemorrhage  is  occurring,  the 
most  absolute  repose  must  be  enjoined  ;  the  patient  should  swallow  as 
rapidly  as  possible  pellets  of  ice  ;  ergotin  should  be  injected  subcuta- 
neously,  as  much  as  three  to  six  grains  at  a  time,  and  it  may  be  repeated 
as  often  as  necessary  ;  a  bag  of  ice  should  be  put  on  the  epigastrium  ; 
and  large  draughts  of  iced  alum-whey  should  be  swallowed  every  few 
minutes.  Ligatures  around  the  thighs,  tied  tightly  enough  merely  to 
stop  a  part  of  the  venous  blood  in  the  lower  limbs,  is  an  excellent 
adjunct  to  the  measures  above  proposed.  If  this  is  not  done,  the  legs 
should  hang  down  out  of  the  bed,  and  the  shoulders  should  be  some- 
what raised.  The  salts  of  iron  (chloride,  nitrate,  subsulphate)  may  be 
administered  for  their  styptic  effect.  A  teaspoonful  of  the  tincture 
of  the  chloride  can  be  given  in  four  ounces  of  ice-water.  An  objection 
to  these  ferruginous  styptics  is  the  very  voluminous  and  nauseating 
coagula  which  they  form,  and  which  are  apt  to  excite  vomiting.  Bran- 
dy is  an  excellent  local  astringent,  and  is  generally  serviceable  in  these 
cases,  owing  to  the  syncope.  The  stimulant  is  beneficial  in  raising  the 
arterial  tension,  by  furnishing  a  force  for  the  vaso-motor  system,  which 
is  in  a  state  of  paralysis.  Tannic  acid  is  a  safe  styptic,  which  can  be 
used  frequently  and  in  relatively  large  (ten  grains)  quantity.  Sulphuric 
acid  may  be  employed  successfully,  and  this  has  the  advantage  that  a 
small  quantity  imparts  astringent  property  to  a  large  amount  of  water. 
Next  to  alum-whey  it  is  the  most  efiicient  haemostatic.  If  vomiting  is 
obstinate,  the  one  sixteenth  grain  of  morphia  hypodermatically  will 
stop  it,  and  contribute  materially  to  the  arrest  of  the  haemorrhage. 

If  the  haemorrhage  has  been  sufficient  to  cause  dangerous  syncope, 
inhalation  of  nitrate  of  amyl  may  arouse  the  failing  heart,  or  the  injec- 
tion of  digitaline  may  be  tried.  Leube  advises  the  subcutaneous  in- 
jection of  ether — a  syi'ingeful  every  few  minutes — in  cases  of  danger- 
ous syncope  from  the  haemorrhage.  Very  great  care  is  subsequently 
required  in  the  alimentation,  and  in  the  use  of  remedies  to  remove  the 


DILATATiOX   OF   THE   STOMACH.  53 

anaemia.  Only  milk  should  be  permitted  for  some  days  ;  but  this  may 
be  supplemented  most  advantageously  by  the  rectal  injection  of  defi- 
brinated  blood. 

DILATATION    OF    THE    STOMACH. 

Causes. — Dilatation  of  the  stomach  is  most  frequently  produced  by 
stenosis  of  the  pylorus.  The  great  cause  of  narrowing  of  the  pyloric 
orifice  is  cancer,  but  it  may  be  due  to  chronic  inflammation,  hyperpla- 
sia, and  subsequent  contraction  of  the  submucous  connective  tissue,  or 
to  hypertrophy  and  contraction  of  the  muscular  elements — the  so-called 
sphincter — of  the  pylorus.  These  forms  of  local  disease,  limited  to 
this  locality,  are  excessively  rare,  while  cancer  is  common.  Exterior 
pressure,  as  of  cancer  of  the  pancreas,  a  floating  kidney  or  other  tumor, 
may  cause  stenosis  of  the  pylorus  and  subsequent  dilatation  of  the 
stomach.  Dilatation  of  the  stomach  may  be  the  result  of  excessive 
indulgence  in  the  use  of  fluids,  notably  of  beer.  The  author  has  ob- 
served several  cases,  in  beer-drinkers,  who  drank  ten,  twenty,  even 
forty,  glasses  of  beer  habitually  every  day. 

Pathological  Anatomy. — When  stenosis  exists  at  the  pylorus,  the 
whole  organ  is  dilated,  often  enormously  so,  but  the  enlargement  is 
not  universal  and  uniform  from  the  beginning ;  the  dilatation  com- 
mences in  the  fundus.  With  the  development  of  the  stenosis  there 
ensues  hypertrophy  of  the  muscular  layer,  in  accordance  vnih  the  well- 
known  pathological  law.  In  dilatation  without  stenosis  of  the  pylorus 
the  muscular  layer  is  thinner  than  normal,  pale  in  color,  and  more  or 
less  advanced  in  fatty  degeneration  ;  the  mucous  membrane  is,  also, 
thin,  pale,  and  without  rugae.  Stenosis  of  the  pylorus  is  caused  chiefly 
by  cancer,  and  hence  the  lesions  peculiar  to  this  new  formation  will  be 
present.  If  ulcers  have  been  excavated  at  the  margin  of  the  orifice, 
have  subsequently  coalesced,  and  cicatrized,  the  results  of  the  contrac- 
tion of  the  cicatricial  tissue  will  be  seen  in  a  distorted  and  contracted 
pylorus. 

Symptoms. — When  stenosis  of  the  pylorus  and  dilatation  of  the 
stomach  are  results  of  cancer  formation,  the  symptoms  of  dilatation 
are  quite  dominated  by  those  of  cancer.  It  is  necessary,  here,  to  dis- 
cuss the  former  only.  The  symptoms  are  those  of  chronic  gastric  ca- 
tarrh, or  of  dyspepsia.  There  are  three  signs  in  addition  to  those  of 
dyspepsia,  which  indicate  dilatation  of  the  stomach  :  rather  persistent 
vomiting  ;  vomiting  of  food  partly  chymified  and  partly  undergoing 
fermentative  and  putrefactive  changes — the  physical  evidence  of  en- 
largement. The  cavity  having  greatly  increased  capacity,  enormous 
accumulations  may  take  place,  and  hence  when  vomiting  occurs  the 
amount  discharged  will  be  great.  The  attacks  of  vomiting  are  more 
frequent  than  is  usual  in  ordinary  cases  of  dyspepsia,  and  they  may 
become  habitual.     Regurgitation  is  a  common  symptom — particles  of 


54  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

partly  digested  aliment,  acid,  acrid,  and  offensive,  and  foul  gases,  com- 
pounds of  hydrogen  with  sulphur  and  phosphorus,  coming  up.  The 
bowels  are  torpid,  the  faeces  dry.  The  nutrition  is  much  impaired  in 
consequence  of  the  insufficient  conversion  of  the  food,  and  the  dimin- 
ished absorption.  Hence  the  patients  affected  with  this  malady  waste, 
and,  as  the  blood  is  deficient  in  water,  they  suffer  from  muscular  cramp, 
chiefly  of  the  flexors.  These  cramps  were  first  described  by  Kussmaul 
(Leube),*  but  the  author  has  repeatedly  observed  them  to  occur  in  can- 
cer of  the  stomach,  in  dilibetes,  etc.,  and  everybody  knows  that  they 
occur  in  Asiatic  cholera,  the  same  cause,  dehydration  of  the  blood, 
operating  in  all  these  maladies. 

The  physical  signs  of  dilated  stomach  are  as  follows  :  On  inspec- 
tion, an  abnormal  fullness  and  prominence  of  the  whole  stomach  region 
will  be  seen  ;  on  percussion,  the  signs  vary  according  to  the  state  of 
the  organ  ;  if  empty,  a  tympanitic  percussion-note,  of  a  somewhat  metal- 
lic quality  and  extending  from  the  sixth  intercostal  space  to  or  below 
the  umbilicus,  is  developed  ;  if  full,  it  is  high  pitched  and  flat,  and,  on 
assuming  the  upright  posture,  there  is  a  zone  of  dullness  at  the  lower 
part  of  the  space,  in  the  recumbent  posture  returning  a  tympanitic 
note.  On  auscultation  of  the  dilated  stomach,  there  is  almost  always 
heard  a  good  deal  of  succussion — splashing  of  the  fluid  in  the  cavity, 
when  the  body  is  suddenly  and  strongly  shaken.  Another  means  of 
diagnosis  consists  in  passing  the  stomach -tube,  and  noting  the  point  at 
which  it  may  be  felt  through  the  abdominal  parietes. 

Course,  Duration  and  Prognosis. — Usually  the  clinical  history  of 
dilated  stomach  is  that  of  the  maladies  causing  it.  When  it  occurs 
independently,  the  course  and  duration  are  rather  indefinite,  and  the 
prognosis  unfavorable  as  to  cure. 

Treatment. — The  first  and  most  important  duty  is  a  careful  adapta- 
tion of  the  diet  to  the  conditions  present.  The  form  of  alimentation 
suitable  to  these  cases  is  "  dry  diet,"  f  a  diet  without  fluids.  The 
quantity  of  other  foods  should  be  small,  and  as  far  as  possible  "  water- 
free." 

As  paresis  of  the  muscular  layer  of  the  stomach  is  an  important 
factor  in  the  dilatation,  means  must  be  employed  to  correct  this. 
Strychnia  hypodermatically,  in  the  epigastrium,  is  an  excellent  expedi- 
ent. Tincture  of  nux  vomica  and  tincture  of  physostigma  are  effective 
remedies — ten  to.  twenty  drops  of  each — three  times  a  day  before 
meals.  Great  benefit  is  obtained  from  the  use  of  galvanism,  one  elec- 
trode placed  just  beneath  the  mastoid  process  and  the  other  at  the 
epigastriiim,  and  a  mild  current  (from  five  to  twenty  cells  of  Siemens 

*  "  Ziemssen's  Cyclopaedia,"  article  "  Diseases  of  the  Stomach,"  vol.  vii. 
f  See  my  Treatise  on  "  Materia  Medica  and  Therapeutics,"  article  "  Alimentation  in 
Disease." 


INTESTINAL   CATARRH.  55 

and  Halske),  slowly  interrupted,  passed  through  the  pneumogastric. 
Fermentation  should  be  prevented  by  the  use  of  the  sulphites,  carbolic 
acid,  etc.,  but  especially  by  abstaining  from  starchy  and  saccharine 
substances,  which  produce  a  great  quantity  of  carbonic-acid  gas.  The 
decomposing  foods,  the  fat  acids  set  free  by  the  fermenting  butter  and 
other  fats,  and  the  unhealthy  mucus  which  is  poured  out  in  great 
quantity,  keep  up  irritation  which  renders  futile  the  use  of  the  ordi- 
nary remedies.  This  fermentative  and  decomposing  mass  must  be  re- 
moved from  the  stomach.  The  expedient  first  advocated  and  employed 
by  Kussmaul — washing  out  the  stomach  with  the  pump  or  siphon — 
has  proved  to  be  useful,  but  it  does  not  maintain  the  same  position,  as 
a  therapeutical  means,  as  on  its  first  introduction.  Recently  Ktister  * 
has  opposed  its  use  on  several  grounds,  and  advised  the  treatment  by 
muriatic  acid,  Carlsbad  salts,  and  nitrate  of  silver.  If  the  stomach- 
pump  or  siphon  be  used,  the  stomach  should  be  thoroughly  washed 
out  every  day.  The  author  can  not  doubt  that,  if  an  emetic  is  first 
given,  and  is  followed  by  an  active  saline  cathartic,  the  stomach 
will  be  thoroughly  emptied,  and  as  efiiciently  as  if  the  stomach-pump 
were  employed.  Then,  if  distention  be  avoided,  a  suitable  diet  en- 
joined, and  remedies  to  promote  contraction  of  the  muscular  layer 
prescribed,  the  best  results  can  be  obtained  of  which  our  present  re- 
sources will  admit. 


DISEASES  OE  THE  E^TESTIKES. 


CATARRH  OF  THE  INTESTINES. 

Deflnition. — Catarrh  of  the  intestinal  mucous  membrane  may  exist 
in  the  acute  or  chronic  form.  It  receives  different  designations  as  it 
affects  the  various  divisions  of  the  intestinal  tract.  Catarrh  of  the 
duodenum  is  duodenitis;  of  the  ilium,  ileitis;  of  the  colon,  colitis; 
and  of  the  ilium  and  colon  together,  ileo-colitis.  When  it  is  limited 
to  the  caecum  it  is  called  typhlitis^  and  when  to  the  rectum,  p>foctitis. 
Again,  the  designation  is  derived  from  some  special  characteristics,  as 
cholera  morbus,  cholera  infantum,  etc. 

To  avoid  repetition,  those  points  in  the  morbid  anatomy  in  which 
these  several  forms  agree  may  be  first  described  with  advantage. 

Pathological  Anatomy  of  Catarrh  of  the  Intestines. — In  the  ca- 

*  "  Allgemeine  Med.  central  Zeitung,"  ISTG,  No.  98. 


56  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

tarrhal  process,  there  ensues  first  hypersemia  of  the  mucous  membrane, 
which  is  manifested  by  redness,  swelling,  and  oedema  ;  next,  nutritive 
alterations,  which  consist  of  granulation  of  the  protoplasm,  over- 
growth and  desquamation  of  the  epithelium.  The  injection  occurs 
most  decidedly  about  the  glands,  but  it  may  be  uniformly  diffused, 
the  whole  surface  affected,  or  the  redness  may  be  in  patches  and  re- 
stricted to  particular  localities.  One  result  of  active  hypersemia  is 
rupture  of  capillaries  and  extravasation  of  blood  ;  another  is  increased 
secretion  and  exudation,  consisting  of  the  products  of  glands,  abnor- 
mally active,  desquamating  epithelium,  proliferating  cells,  and  migrat- 
ing white  corpuscles.  In  these  changes  consists  the  morbid  anatomy 
of  an  acute  catarrh  of  a  mucous  membrane. 

In  chronic  catarrh,  which  succeeds  to  the  acute  form,  generally, 
the  changes  ax'e  similar,  but  possess  also  special  character.  Long-con- 
tinued hypersemia  induces  changes  in  the  vessels — over-distended  they 
remain  enlarged,  the  veins  tortuous  and  varicose  ;  remains  of  old  ex- 
travasations of  blood  are  seen  in  a  brownish,  slate-colored  pigment 
deposit,  most  abundant  in  the  villi.  The  mucous  membrane  contin- 
ues swollen  and  oedematous  ;  the  cells  of  the  epithelial  layer  are  altered 
in  respect  to  their  nuclei  and  protoplasm,  which  have  become  cloudy 
and  are  more  or  less  advanced  in  fatty  degeneration.  The  glands  and 
agminated  follicles  become  prominent  from  an  excessive  formation 
and  accumulation  of  their  contents  ;  as  a  result  of  the  pressure  of 
proliferating  cells,  necrosis  occurs,  and  sloughs  separate,  leaving  ul- 
cers ;  or  the  glands  remain  prominent  and  brownish  and  slate-colored 
from  changes  in  previous  extravasations.  The  mucous  membrane  is 
covered  with  a  tenacious  mucus  rich  in  pus-cells,  which  strongly  ad- 
heres, or  with  a  more  abundant  and  less  tenacious  purulent  exudation. 
Owing  to  an  accumulation  of  their  contents,  the  agminated  patches 
with  solitary  follicles  are  enlarged,  their  orifices  appearing  as  minute 
black  points,  the  whole  forming  a  very  characteristic  appearance. 

In  chronic  catarrh  the  anatomical  alterations  are  not  limited  to  the 
mucous  membrane  and  its  glandular  appendages.  The  hypersemia  ex- 
tends to  the  mucosa  ;  its  vessels,  especially  the  veins,  enlarge,  and  the 
connective  tissue,  in  some  situations,  undergoes  hyperplasia  and  thick- 
ens, forming  prominences.  Instead  of  hypertrophy,  an  atrophic  change 
may  result  from  chronic  catarrh,  but  a  very  great  duration  of  the  dis- 
ease and  the  immaturity  of  early  life  are  necessary. 

The  muscular  layer  of  the  intestine,  if  a  catarrh  has  long  per- 
sisted, may  undergo  hypertrophy,  and,  in  rare  cases,  to  such  an  ex- 
tent as  to  encroach  on  the  cavity  and  greatly  lessen  the  capacity  of 
the  bowel. 


CHOLERA  MORBUS.  57 

CHOLERA  MORBUS. 

Definition. — An  acute  catarrh  of  tlie  stomacli  and  intestines,  of  sud- 
den onset,  and  manifested  objectively  by  yomiting  and  purging.  It 
is  also  called  cholera  nostras,  sporadic  cholera,  etc. 

Causes. — Climatic  influences  are  the  most  important.  It  is  a  dis- 
ease more  especially  of  summer  and  early  autumn,  although  it  may 
occur  under  certain  circumstances  at  any  season.  Tartar  emetic,  ela- 
terium,  and  other  irritants  will  bring  on  vomiting  and  purging  not  to 
be  distinguished  from  a  severe  cholera  morbus.  Irritants  of  all  kinds, 
unripe  fruits  and  vegetables,  fermentation  of  foods  in  the  stomach, 
will  excite  an  attack. 

Pathological  Anatomy. — Death  may  ensue  without  there  being  any 
defined  alterations  of  structure.  In  ordinary  cases  there  are  present 
the  changes  of  acute  gastro-intestinal  catarrh  ;  the  mucous  membrane 
hyperfemic  ;  the  epithelium  desquamating  ;  the  glands  swollen  and 
prominent  ;  the  blood,  thick  and  of  a  prune- juice  color  ;  the  serous 
membranes  everywhere  dry,  sticky,  and  coated  with  desquamated 
epithelium  ;  the  kidneys  hyperaemic,  the  epithelium  of  the  tubules 
also  being  cast  off ;  the  muscles  of  the  body  becoming  granular,  etc. 
— the  morbid  anatomy,  indeed,  of  true  cholera,  except  in  degree. 

Symptoms. — An  attack  of  cholera  morbus  may  be  preceded  by 
some  diarrhoea,  nausea,  a  coated  tongue,  and  general  malaise  for  a  day 
o'r  two,  but  usually  it  sets  in  suddenly  and  with  violence.  In  the 
night,  as  a  rule,  and  usually  after  midnight,  the  patient  is  awakened 
by  a  chill  or  a  sense  of  chilliness,  some  intestinal  pain  (colic)  and  nau- 
sea, and  vomiting  then  begins  ;  or,  without  any  premonition,  the  pa- 
tient awakes  with  intense  nausea,  and  then  vomits  immediately.  The 
vomited  matters  at  first  consist  of  the  ordinary  contents  of  the  stom- 
ach. Simultaneously,  purging  begins,  the  first  evacuation  containing 
more  or  less  of  ordinary  faeces.  Presently  the  matters  discharged  by 
vomit  and  stool  are  liquid,  whitish,  or  of  a  green  or  yellowish  tint, 
consisting  of  mucus  and  sero-mucus.  In  the  severe  cases,  approxi- 
mating to  the  true  cholera  type,  the  matters  vomited  or  passed  by 
stool  are  copious,  thin,  whitish,  odorless,  or  having  a  faint  mouse-like 
odor,  and  consist  of  blood-serum  with  mucus  and  cast-off  epithelium 
(rice-water  discharges).  The  discharges  occur  in  quick  succession, 
and  so  enormous  is  the  loss  of  material  that  in  an  hour  or  two  the  pa- 
tient may  be  so  much  reduced  as  to  be  unable  to  rise  from  the  bed  ;  the 
body  shrinks,  the  face  becomes  pinched  and  cyanosed,  the  surface  cold 
and  covered  with  a  clammy  sweat  ;  the  hands  shrivel  and  have  a  sod- 
den appearance  ;  the  voice  is  husky,  the  tongue  is  cold,  the  breath  is 
cold.  The  patient  is  tormented  with  an  intolerable  thirst,  but  the  drink 
is  rejected  as  soon  as  swallowed.  The  urinary  secretion  rapidly  di- 
minishes in  amount,  and  in  the  worst  cases  is  suspended.     The  urine 


58  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

contains  traces  of  albumen,  casts  of  the  tubules — the  desquamated 
epithelium — and  is  deficient  in  the  amount  of  urea  and  salts.  The 
effect  of  this  enormous  waste  from  the  intestinal  canal  is  to  diminish 
the  water  of  the  blood,  and  hence  to  relax  the  circulation.  The  action 
of  the  heart  becomes  so  feeble  that  the  pulse  may  not  be  felt  at  the 
wrist.  Another  result  of  the  dehydration  of  the  tissues  is  the  occur- 
rence of  cramps,  especially  in  the  muscles  of  the  calf,  and  they  cause 
severe  suffering,  the  patient  crying  out  when  they  come  on.  They 
may  occur  in  the  muscles  of  the  upper  extremity,  and  also  in  the  mus- 
cles of  the  neck.  In  some  cases,  enormous  accumulation  of  the  rice- 
water  material  may  take  place  because  of  a  paralytic  state  of  the 
bowel,  and  no  discharge  occur  by  vomit  or  stool,  yet  the  patient  passes 
quickly  into  collapse. 

From  the  simplest  case  of  cholera  morbus,  which  ends  spontane- 
ously when  the  stomach  and  intestines  are  emptied,  up  to  the  severe 
algid  form,  there  are  numerous  intermediate  examples  of  every  degree 
of  severity. 

The  subsequent  clinical  history  of  the  cases  depends  much  ou  the 
severity  of  the  attack.  The  mild  case  terminates  without  treatment, 
and  the  next  day,  although  somewhat  weak,  the  patient  is  about  as 
usual.  In  the  severer  cases,  after  several  hours  the  number  of  the 
evacuations  lessens,  and  their  character  is  changed,  the  skin  becomes 
warm,  the  pulse  rises,  and  the  normal  is  presently  restored,  but  the 
mucous  membrane  remains  sensitive,  and  care  in  alimentation  is  neces- 
sary for  several  days.  In  the  severest  cases — those  of  the  cholera 
type — recovery  from  the  algid  stage  is  gradual,  reaction  comes  on 
slowly,  but  passes  the  norm  into  a  fever,  of  type  remittent  and  of 
character  typhoid,  which  may  continue  a  week  or  more.  In  the  fatal 
cases,  the  mode  of  dying  is  by  collapse,  or  in  the  secondary  fever  by 
exhaustion. 

Course,  Duration,  and  Termination. — The  cases  are  very  uniform, 
but  differ  much  in  severity.  The  duration  is  from  a  few  hours  to 
two  or  more  days,  and,  in  the  rare  cases  of  secondary  fever,  to  two 
weeks.  The  termination  is  in  a  great  majority  of  cases  in  health,  the 
mortality  being  about  three  per  cent,  of  uncomplicated  cases.  An 
attack  of  cholera  morbus  may  be  the  mere  prelude  to  an  acute  diarrhoea 
or  dysentery,  more  frequently  the  latter.  An  attack  of  cholera  mor- 
bus may  be  the  mode  of  dying  from  chronic  interstitial  nephritis. 

Diagnosis. — The  phenomena  attendant  on  cholera  morbus  are  so 
characteristic  that  a  mistake  of  diagnosis  would  seem  to  be  difficult. 
During  the  existence  of  a  cholera  epidemic,  the  severer  cases  of  chol- 
era morbus  may  be  mistaken  for  cholera,  but,  as  they  do  not  differ  in 
any  respect,  not  even  in  morbid  anatomy,  there  need  be  no  attempt  at 
differentiation.  Cholera  morbus,  a  substantive  affection,  may  be  con- 
founded with  choleriform  attacks  due  to  uraemia.     The  distinction  is 


CHOLERA   MORBUS.  59 

to  be  made  by  reference  to  the  previous  history,  the  presence  of 
albumen  and  casts  in  the  urine,  and  the  cerebral  symptoms,  which,  in 
some  form,  occur  in  uraemia. 

Treatment. — In  simple  cholera  morbus  due  to  the  ingestion  of  some 
irritating  or  indigestible  food,  or  to  fermenting  materials,  no  treat- 
ment may  be  necessary.  When  the  cause  is  removed  the  morbid 
action  ceases.  In  the  more  severe  cases  prompt  action  is  necessary, 
especially  when  cholera  is  prevalent.  No  remedy  compares  in  effi- 
ciency to  the  hypodermatic  injection  of  morphia  and  atropia — ^  to 
^  of  a  grain  of  the  former  and  yiir  of  a  grain  of  the  latter.*  Those 
entirely  unaccustomed  to  the  action  of  opium — women,  and  men  of  the 
nervous  and  impressionable  type — should  receive  the  smaller  dose.  In 
many  cases,  a  single  injection  suffices  to  tenninate  the  attack.  The 
repetition  of  the  injection  will  depend  on  the  severity  and  persistence 
of  the  attack,  and  on  the  susceptibility  of  the  patient.  It  is  usually 
better  not  to  repeat  the  injection  within  the  hour.  The  effect  which 
it  has  is  most  striking :  the  vomiting  and  purging  cease,  the  pulse 
rises,  the  surface  becomes  warm,  and  the  cramps  are  no  longer  felt.  It 
is  rare,  indeed,  if  these  results  are  not  obtained  promptly,  rendering 
unnecessary  any  subsequent  treatment  except  some  correcting  medi- 
cine In  the  cases  of  the  cholera  type,  the  patient  passing  into  the 
algid  stage,  additional  means  may  be  necessary.  The  use  of  chloral 
hypodermatically  with  morphia  is  then  remarkably  beneficial.  The 
author  has  observed  that  under  these  circumstances  chloral  will  re- 
lieve the  cramps  and  bring  about  reaction,  when  morphia,  alone  or 
with  atropia,  had  seemed  inadequate. 

Other  means  of  treatment  may  be  employed  in  conjunction  with 
the  hypodermatic  injections,  or  without  them.  Sinapisms  of  large  size 
should  be  applied  to  the  abdomen,  but  not  allowed  to  remain  longer 
than  sufficient  to  produce  a  sensation  of  burning,  or  the  appearance  of 
redness.  Pellets  of  ice  may  be  repeatedly  swallowed.  Iced  cham- 
pagne, very  dry,  will  sometimes  be  retained  when  other  things  are 
rejected.  Carbonic-acid  water  and  effervescing  soda-powders  are  very 
grateful  and  also  serviceable.  The  medicines  most  easily  borne  and 
most  efficient  are  combinations  of  the  mineral  acids  and  opium,  of 
which,  the  well-known  Hope's  mixture  is  a  type.  Diluted  sulphuric 
or  muriatic  acids  witli  the  tincture  of  opium  in  camphor-water,  are 
the  best  of  these  combinations.  The  mistake  is  frequently,  indeed, 
usually  made,  of  giving  the  mineral  acids  in  too  large  doses,  and 
hence  they  are  immediately  rejected.  From  two  to  five  drops  of  di- 
luted sulphuric,  or  the  same  dose  of  diluted  muriatic  acid,  and  the 
same  quantity  of  tincture  of  opium,  should  be  given  from  every  half 
hour  to  every  two  hours,  in  a  sufficient  qiiantity  of  ice-water.     An 

*  "  Manual  of  Hypodermic  Medication,"  third  edition.  Philadelphia :  J.  B.  Lippin- 
cott  &  Co.,  ISYQ. 


QQ  DISEASES   or  THE   DIGESTIVE   SYSTEM. 

acid  solution  is  much  more  grateful,  and  also  more  easily  borne,  than 
any  other  kind  of  medicine.  Carbolic  acid  alone,  or  in  a  mixture  with 
bismuth,  is  an  efficient  means  for  arresting  vomiting.  Beside,  its 
properties  as  an  antiferment,  it  has  a  local  anaesthetic  action  on  the 
terminal  filaments  of  the  nerves  in  the  mucous  membrane.  The  ef- 
fects of  carbolic  acid,  creosote,  and  other  agents  of  the  same  kind,  are 
confined  to  the  stomach,  and  hence  they  are  of  little  use  in  affections 
of  the  intestines.  Iodine  tincture,  and  carbolic  acid,  in  equal  parts — 
a  half  grain  of  each — every  half  hour,  is  an  effective  combination,  of 
great  utility  in  irritable  stomach.  When  remedies  of  the  kind  just 
now  mentioned  are  given  by  the  stomach,  they  should  be  supple- 
mented by  enemata  of  starch  and  laudanum,  repeated  according  to 
circumstances. 

Very  small  doses  of  calomel — one  twelfth  to  one  sixth  of  a  grain — 
have  remarkable  sedative  effect  on  the  gastro-intestinal  mucous  mem- 
brane, relieving  vomiting  and  suspending  the  purging.  It  is  often 
given  with  opium,  with  rhubarb,  piperine,  etc.,  but  such  combinations, 
except  that  with  opium,  are  of  doubtful  utility.  Aromatic  and  astrin- 
gent remedies  are  much  used  in  various  combinations  to  arrest  vomit- 
ing and  purging.  Tincture  of  rhubarb,  tincture  of  colomba,  and  tinc- 
ture of  opium,  make  an  effective  remedy.  One  of  the  most  generally 
useful  and  certain  remedies  for  attacks  of  cholera  morbus  is  chloro- 
dyne.  As  a  secret,  proprietary  remedy  it  should  not  be  prescribed, 
but  one  of  the  more  accurately  prepared  imitations  of  the  original 
compound  can  be  substituted.  There  can  be  little  doubt  now  that 
this  is  a  fortunate  combination  of  remedies,  adapted  to  the  treatment 
of  gastro-intestinal  maladies  having  the  choleriform  character. 

CHOLERA  INFANTUM. 

Definition. — An  acute  gastro-intestinal  catarrh,  occurring  in  chil- 
dren during  the  period  of  the  first  dentition,  and  characterized  by 
vomiting,  purging,  and  considerable  febrile  excitement.  It  is  also 
called  summer  cholera  and  summer  complaint  in  domestic  prac- 
tice. 

Causes.— Early  life— the  first  two  years— owing  to  the  various 
phases  through  which  the  organism  is  then  passing,  is  the  period  for 
cholera  infantum.  Bad  hygiene  is  the  great  factor— including  damp, 
ill -ventilated,  and  confined  houses,  air  contaminated  by  cesspool  and 
sewer  emanations,  continuous  high  temperature,  and  improper  food. 
Feeding  infants  the  coarse  food  of  adults,  or  confining  them  to  a  diet 
composed  almost  entirely  of  starch,  are  most  fruitful  causes  of  an  out- 
break of  the  disease,  the  other  conditions  being  present.  This  peculiar 
form  of  gastro-intestinal  catarrh  occurs  chiefly  in  cities,  in  low,  ma- 
larious localities,  and  is  especially  frequent  on  this  side  of  the  Atlan- 


CHOLERA   INFANTUM.  01 

tic.  But  Berlin  has  the  bad  preeminence,  according  to  Lombard,*  of 
surpassing  the  American  cities  in  "  the  frequency  of  the  cholera  of 
infants." 

Pathological  Anatomy. — The  changes  occurring  in  cholera  infan- 
tum are  those  described  under  the  general  head  of  catarrh  of  the 
intestines.  The  implication  of  the  solitary  glands  and  the  agminated 
(Peyer's)  patches  is  somewhat  more  decided  than  is  there  stated,  prob- 
ably, but  otherwise  the  description  there  given  is  accurate.  A  marked 
degree  of  cerebral  anaemia  is  represented  in  a  venous  stasis,  and  a  good 
deal  of  fluid  in  the  subarachnoid  spaces. 

Symptoms. — This  disease  sets  in  by  two  modes  of  onset :  with  pre- 
liminary symptoms  ;  suddenly.  Usually  there  are  prodromes,  the  child 
becoming  restless,  irritable,  feverish,  before  any  bowel  symptoms  are 
manifest,  then  diarrhoea  comes  on,  vomiting  occurs,  and  the  disease  is 
fully  developed.  In  other  cases  diarrhoea  has  persisted  several  weeks 
with  the  usual  symptoms,  and  gradually  the  phenomena  of  cholera 
infantum  are  added.  Again,  the  disease  is  suddenly  developed  :  the 
child,  in  full  health,  is  attacked,  without  any  preliminary  symptoms, 
with  the  characteristic  vomiting  and  purging.  The  first  evacuations 
contain  more  or  less  fecal  matter,  but  soon  the  characteristic  watery 
stools  make  their  appearance.  These  are  so  thin  as  to  soak  into  the 
napkin;  leaving  a  greenish  or  greenish-yellow  stain,  and  having  an  odor 
of  rotten  wood,  or  indeed  having  but  little  odor.  With  these  stools 
are  particles  of  curd,  or  undigested  food  passed  as  swallowed,  or  yel- 
lowish masses  of  mucus  turning  green  on  exposure.  Simultaneously 
vomiting  occurs  of  any  food  or  drink  swallowed,  and  with  these  mat- 
ters a  quantity  of  sero-mucus,  acid,  neutral,  or  even  alkaline,  according 
to  the  time  of  the  vomiting.  Usually  anything  taken  into  the  stomach 
—  water  or  mother's  milk  —  is  rejected  immediately;  the  retching 
continues,  and  the  mucus  coming  up  after  the  food  is  acid  ;  further 
retching  brings  up  some  serous  fluid,  which  is  neutral,  and  alkaline 
if  it  comes  from  the  duodenum.  Prolonged  retching  brings  up  not 
only  the  contents  of  the  duodenum,  but  mucus  and  bile  from  the  gall- 
bladder. The  loss  by  the  gastro -intestinal  mucous  membrane  induces 
rapid  wasting.  In  a  few  hours  the  body  shrinks  remarkably,  the  eyes 
are  sunken  and  half  closed  ;  the  mouth  remains  half  open,  the  lips  dry 
and  cracked,  and  bleeding,  for  the  infant  feebly  picks  at  the  fissures  ; 
the  face  is  shrunken,  pallid,  with  an  occasional  red  spot  in  the  cheeks. 
More  or  less  pain  is  felt  when  the  bowels  are  moved  or  when  vomiting 
is  about  to  take  place,  which  the  child  manifests  by  restlessness  and  a 
husky  whine  or  cry.  Tenderness  on  pressure  usually  exists  along  the 
track  of  the  colon,  and  an  erythematous  rash  diffuses  from  the  anus 
over  the  buttocks  and  genitalia,  causing  so  much  tenderness  that  the 

*  "Traite  de  Climatologie  Medicale,"  vol.  iv,  p.  Z11.     Paris:  Bailliere  et  Fils,  18S0. 


62  DISEASES  OF  THE   DIGESTIVE   SYSTEM. 

contact  of  the  irritating  discharges  excites  pain.  The  mind  is,  how- 
ever, rather  torpid,  the  senses  not  acute,  and  the  attention  roused  only 
by  strong  excitation.  The  child  lies  at  last  in  a  condition  of  great 
exhaustion,  indifferent  to  all  surrounding  objects,  and  experiencing 
the  distress  which  comes  from  thirst  only. 

Rise  of  temperature  takes  place  with  the  first  disturbance  of  the 
intestinal  canal,  the  fever  being  of  the  remittent  type,  with  the  remis- 
sion in  the  morning,  usually.  In  the  early  morning  is  the  period  of 
greatest  depression.  With  the  rise  of  temperature  in  the  afternoon, 
the  cheeks  may  be  a  little  flushed,  and  the  countenance,  therefore, 
appear  better.  The  range  of  temperature  taken  in  the  axilla  is  from 
102°  to  104°  Fahr.  in  the  pronounced  cases.  The  pulse  is  very  rapid 
and  feeble — 140  to  160  beats  in  the  minute.  The  number  of  dis- 
charges may  rise  to  forty  or  fifty  a  day,  many  of  them  not  more  than  a 
teaspoonful  of  fluid.  With  the  progress  of  the  case,  there  is  a  rapid 
decline  in  weight  and  strength  ;  the  pulse  becomes  more  quick  and 
feeble  ;  the  respirations  grow  more  and  more  shallow,  and  hypostatic 
congestion  and  oedema  occur  ;  carbonic-acid  poisoning  ensues,  with  a 
gradually  deepening  coma,  ending  in  death. 

Course,  Duration,  and  Terminations. — The  ordinary  course  is  prompt 
in  the  fatal  tendency,  or  toward  cure,  the  latter  being  the  natural  ten- 
dency when  the  child  is  j^ut  under  favorable  hygienic  conditions.  The 
duration  of  the  attack  proper  is  two  or  three  days  to  one  week ;  severe 
cases  may  terminate  .in  collapse  in  a  day  or  two.  When  recovery  en- 
sues, the  duration  of  the  case  is  prolonged  by  the  subsequent  ileo-colitis. 
If  the  prodromic  symptoms  are  included,  it  may  be  said  that  the  aver- 
age cases  are  from  one  to  two  weeks,  not  including  the  ileo-colitis  or 
the  proctitis,  which  may  prolong  the  attacks  several  weeks.  The  most 
frequent  termination  is  by  exhaustion  and  death  by  coma  from  defi- 
cient excretion  of  carbonic  acid  and  its  accumulation  in  the  blood. 
The  cerebral  anaemia  may  be  confounded  with  acute  cerebral  conges- 
tion, and  the  death  attributed,  very  erroneously,  to  the  latter.  Death 
may  happen  at  the  lungs  or  from  failure  of  the  heart. 

Diagnosis. — The  only  disease  with  which  cholera  infantum  can  be 
confounded  is  true  cholera,  but,  as  the  therapeutical  indications  are  the 
same,  it  is  the  less  important  to  be  correct. 

Prognosis. — A  guarded  opinion  should  always  be  given,  as  the  case 
may  very  unexpectedly  take  an  unfavorable  turn.  The  hygienical 
surroundings  influence  the  prognosis  greatly.  The  number  and  fre- 
quency of  the  discharges  and  the  readiness  with  which  the  symptoms 
yield  to  the  treatment  are  important  elements  in  making  up  a  judg- 
ment. The  constitutional  condition,  the  inherited  tendencies,  and  the 
aliment  available  for  nutrition,  are  to  be  carefully  considered.  When 
the  child  is  at  the  breast,  and  the  supplj^  of  milk  is  abundant  and  good, 
the    prognosis    may    be    more  favorable  than  if  the   child  has  been 


CHOLERA   INFANTUM.  63 

weaned,  and  the  kind  of  aliment  suitable  to  tlie  case  remains  un- 
determined. 

Treatment. — Immediate  attention  must  be  given  to  the  aliment. 
Instead  of  large  draughts  of  water,  the  child  should  suck  some  pieces 
of  ice.  If  nursing,  the  number  and  duration  of  applications  to  the 
breast  must  be  regulated.  The  child  is  excessively  thirsty,  and  is  in- 
cessant in  the  demands  for  nursing.  The  stomach  is  quite  unable  to 
dispose  of  it,  and  it  is  either  soon  rejected  or  passes  by  the  bowels. 
Once  in  two,  two  and  a  half,  or  three  hours,  according  to  the  age,  is 
often  enough,  and  the  child  should  be  removed  when  it  has  obtained 
two  tablespoonfuls.  If  fed  by  cow's  or  goat's  milk,  this  should  be 
diluted  with  lime-water.  If  they  do  not  agree,  owing  to  an  inability 
to  digest  the  casein,  which  is  the  usual  difficulty,  the  best  substitute  is 
barley-water,  of  the  density  of  good  milk,  to  which  cream  is  added  in 
the  proportion  in  which  it  exists  in  milk.  This  combination  is  a  nutri- 
tious aliment  of  the  quality  of  milk,  less  the  casein.  Beef -tea  is  veiy 
badly  borne  in  these  cases,  and  the  artificial  foods  prepared  for  infants 
are  not,  in  the  author's  experience,  good  substitutes  for  milk.  One  of 
the  most  important  remedial  agents  is  the  cold  bath.  The  extraordi- 
nary temperature  range,  almost  reaching  hyperpyrexia,  is  an  important 
element  of  danger,  causing  failure  of  the  heart  and  paralysis  of  the 
brain.  The  cold  bath  is  the  most  effective  means  of  combating  the 
fever.  The  child  must  be  very  gently  and  carefully  immersed  in 
water  at  95°  to  100°  Fahr.,  and  the  cold  water  gradually  added  until 
the  thermometer  stands  at  85°  or  80°,  or  even  60°,  if  well  borne.  The 
duration  of  the  bath  is  about  ten  minutes,  and  the  frequency  of  their 
repetition  depends  on  the  influence  which  they  have  on  the  tempera- 
ture. Two  or  three  baths  per  day  are  required  until  the  fever  perma- 
nently declines. 

The  administration  of  pure  cognac  brandy,  in  a  small  quantity  of 
very  cold  water,  is  an  excellent  means  of  checking  the  vomiting  and 
purging,  and  of  lessening  the  abnormal  heat.  From  twenty  minims  to 
one  drachm  every  two,  three,  or  four  hours,  according  to  the  age  of 
the  subject  and  the  severity  of  the  symptoms,  is  the  proper  amount 
for  administration.  The  opium  so  much  prescribed,  and  so  remarkably 
beneficial  in  cholera  morbus — a  similar  state  in  the  adult — ^is  a  remedy 
whose  utility  is  most  questionable.  In  the  author's  judgment,  opium 
should  be  given  only  when  the  other  means  used  has  no  effect  in  re- 
straining the  excessive  discharges.  A  most  efficient  jDrescription  is  the 
combination  of  bismuth  and  carbolic  acid — ten  grains  of  the  former, 
and  one  fourth  to  one  half  grain  of  the  latter,  every  two  hours.  It  is 
best  administered  with  some  tincture  of  cinnamon  in  an  emulsion  of 
gum-arabic.  It  may  be  given  also  with  mistura  cretse.  Rhubarb,  in 
doses  that  are  merely  astringent,  with  an  aromatic  (cinnamon)  and  an 
alkali  (bicarbonate  of  potassium),  is  an  efficient  remedy,  especially  in 


64  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

this  combination.  Infusion  of  rhubarb,  tincture  of  cinnamon,  with 
some  bicarbonate  of  potassium,  makes  a  disagreeable  but  extremely- 
serviceable  prescription  in  these  cases.  Oxide  of  zinc,  oxide  of  silver, 
nitrate  of  silver,  are  useful  in  those  cases  characterized  by  severe  watery 
purging  rather  than  vomiting.  When  the  vomiting  is  excessive,  and 
other  medicines  are  rejected,  calomel  is  extremely  beneficial,  and,  in- 
deed, in  ordinary  cases,  it  has  the  first  position  almost  as  a  sedative  to 
the  gastro-intestinal  mucous  membrane.  It  must  be  given  in  very 
small  doses — one  twentieth  to  one  tenth  of  a  grain,  every  half  hour  or 
hour.  It  may  be  rubbed  up  with  some  sugar  of  milk  and  dropped  on 
the  tongue.  When  there  is  much  straining,  and  especially  if  there  be 
much  mucus,  and  mucus  streaked  with  blood,  passed  from  the  bowels, 
minute  doses  of  arsenic  (from  one  eighth  to  one  fourth  drop  of  Fow- 
ler's solution)  with  a  little  opium  (half  to  one  drop),  every  three  hours, 
are  very  serviceable.  If  the  discharges  are  very  profuse,  watery,  and 
not  restrained  by  the  remedies  prescribed  by  the  stomach,  enemata  of 
starch  and  laudanum  may  be  used.  Counter-irritation  by  mustard 
(the  skin  very  little  reddened  or  irritated),  or  by  means  of  a  spice-bag, 
or,  better,  a  turpentine-stupe,  is  beneficial,  if  not  carried  too  far. 


DUODENITIS— CATARRH  OP  THE  DUODENUM. 

Definition. — Catarrh  of  the  mucous  membrane  of  the  duodenum, 
which  may  be  acute  or  chronic.  As  the  ductus  communis  choledochua 
opens  into  that  part  of  the  canal,  the  catarrhal  process  extends  up  by 
contiguity  of  tissue,  and  hence  catarrhal  jaundice  may  coexist  with 
duodenitis. 

Etiology. — Climatic  changes  are  very  influential  in  setting  up  a 
catarrh  of  the  duodenum.  External  irritation,  if  severe  and  prolonged, 
will  cause  hypersemia  and  structural  changes,  just  as  a  severe  burn  will 
excite  ulceration.  Probably  the  most  common  cause  is  indigestible 
aliment,  which  passes  the  stomach  unchanged,  and  the  excessive  use 
of  starchy,  saccharine,  and  fatty  foods,  which  require  for  their  diges- 
tion and  absorption  the  action  of  the  intestinal  juices,  of  the  bile,  and 
of  the  pancreatic  fluid. 

Pathological  Anatomjo — The  general  description  already  given  ap- 
plies here.  Hyperaemia  and  oedema  occur  to  a  more  pronounced  extent 
about  the  orifice  of  the  common  bile-duct,  which  is  so  swollen  as  to 
encroach  materially  on  the  lumen.  More  or  less  injection  and  swelling 
of  the  mucous  lining  of  the  duct  exist  to  a  variable  extent. 

Symptoms. — The  anatomical  seat  of  the  inflammation  influences,  to 
a  great  extent,  the  symptoms.  In  other  cases  of  intestinal  catarrh, 
diarrhoea  is  a  prominent  symptom  ;  in  duodenitis,  diarrhoea  is  excep- 
tional, and  more  or  less  constipation  is  the  rule.  Pain  and  disorders 
of  digestion  are  usually  present,  and  jaundice  is  a  prominent  symptom. 


DUODEXITIS.  65 

The  pain  is  felt  in  the  right  hypochondi'iac  and  umbilical  regions,  and 
soreness  can  be  developed  by  deep  pressure  over  the  duodenum.  The 
pain  is  not  usually  very  acute — the  sensation  is  compounded  of  pain 
and  soreness,  but  occasionally  severe  pain  occurs  in  the  hepatic  plexus. 
As  in  catarrh  of  the  stomach  there  are  occasional  attacks  of  gastralgia, 
so  in  catarrh  of  the  duodenum  there  are  occasional  attacks  of  hepatal- 
gia.  The  paroxysms  of  severe  pain  come  on  gradually,  and,  after 
some  hours,  gradually  subside.  There  is  no  increased  soreness  during 
the  existence  of  the  pain  or  subsequently. 

There  may  or  may  not  be  present  gastric  catarrh,  as  well  as  duo- 
denitis. The  distress  caused  by  the  presence  of  food  is  felt  about 
three  hours  after  it  has  been  taken,  and  is  usually  referred  by  the 
patient  to  the  seat  of  the  disease.  The  starchy  and  saccharine  ele- 
ments of  the  food  undergo  fermentation,  and  hence,  in  about  three 
hours  after  they  have  been  swallowed,  the  formation  of  flatus  begins, 
the  small  intestines  become  distended  with  gas,  and  some  pain,  due  to 
the  stretching  -of  the  bowel,  is  felt  about  the  umbilicus.  From  the 
third  to  the  seventh  day  jaundice  appears.  It  is  usually  announced  by 
a  coated  tongue,  fetid  breath,  and  yellowness  of  the  conjunctiva,  head- 
ache, stupor,  and  hebetude  of  mind  (cholgemia),  with  depression  of 
spirits.  The  yellowness  extends,  and  in  a  short  time  the  jaundice  is 
universal.  The  absorption  of  bile  is  coincident  with  swelling  of  the 
common  duct,  and  entire  absence  of  bile  in  the  intestinal  canal. 
The  stools  now  have  a  pasty  consistence,  of  a  slate-color,  and  fetid 
odor.  Gas,  discharged  previously,  had  but  little  odor ;  after  the 
jaundice,  it  has  the  same  fetid  character  as  the  stools.  The  urine 
is  thick  from  excess  of  urates,  and  of  a  deep-brownish  color  from 
presence  of  bile-pigment.  When  the  jaundice  has  attained  the  maxi- 
mum, there  are  complete  anorexia,  nausea,  sometimes  vomiting  of 
food,  mucus,  sero-mucus,  and  constipation,  although  diarrhoea  may 
occur. 

The  temperature  is  slightly  elevated — 99*5°  Fahr.  in  the  morning 
and  100°  to  101°  Fahr,  in  the  evening.     Pulse  corresponds. 

Course,  Duration,  and  Termination. — The  disease  is  self-limited, 
and,  if  permitted  to  pursue  its  course  uninterrupted,  will  last  two  or 
three  weeks,  leaving  the  patient  much  debilitated.  In  malarious  dis- 
tricts this  malady  is  exceedingly  common,  and  may  be  intimately  asso- 
ciated with  malarial  infection.  The  chronic  form  of  duodenitis  is 
essentially  the  same  in  respect  to  clinical  history  and  characters,  except 
as  to  duration  and  violence  of  the  symptoms,  as  the  acute  form.  The 
duration  of  the  chronic  form  may  be  several  months.  The  late  re- 
searches of  Charcot  and  Fagge  have  demonstrated  that  long-continued 
obstacle  to  the  outflow  of  bile  leads  to  structural  changes  in  the  liver. 
The  termination  of  uncomplicated  duodenitis  is  in  health.  The  acute 
is  apt  to  pass  into  the  chronic  form,  and  the  latter  to  affect  the  hepatic 
5 


66  DISEASES   OF   THE  DIGESTIVE   SYSTEM. 

parenchyma  in  the  manner  to  be  hereafter  described.     Hepatic  colic  is 
also  one  of  the  results  of  this  disease. 

Diagnosis. — Duodenal  catarrh  may  be  confounded  with  gastric 
catarrh,  with  hepatic  colic,  and  with  diseases  of  the  liver  proper, 
accompanied  by  jaundice.  As  resj)ects  gastric  catarrh,  the  differen- 
tiation is  to  be  made  by  reference  to  the  seat  of  pain  and  soreness,  the 
time  when  the  distress  from  the  presence  of  food  comes  on,  the  occur- 
rence of  flatulence  with  bowel-pain,  and  especially  the  appearance  of 
jaundice  at  a  certain  time  after  the  beginning  of  the  symptoms.  Duo- 
denal catarrh  is  separated  from  hepatic  colic  by  the  following  signs  : 
In  the  latter,  the  pain  comes  on  suddenly  after  some  pain  and  sore- 
ness in  the  region  of  the  gall-bladder,  and  radiates  from  this  point 
over  the  abdomen  ;  the  pain  is  so  intense  as  to  produce  a  cold  sur- 
face, a  weak  pulse,  great  depression,  and  incessant  vomiting  ;  the 
pain  suddenly  ceases,  and  there  is  complete  relief,  except  some  local 
tenderness  ;  jaundice  follows  these  symptoms,  but  disappears  in  a 
few  days,  leaving  the  j^atient  well ;  the  presence  of  a  gall-stone  in  an 
evacuation  a  few  days  after  the  attack.  Hepatalgia  is  a  neuralgic 
attack,  occurring  suddenly,  and  lim.ited  to  the  hepatic  plexus.  It 
ceases  suddenly,  leaving  the  patient  well,  and  the  only  interference 
with  function  is  during  the  existence  of  pain.  Its  duration  is  but  a 
few  hours. 

Treatment. — The  first  point  is  regulation  of  the  diet.  The  diet 
should  be  restricted  to  those  substances  convertible  into  peptones  in 
the  stomach,  as  milk,  whey,  buttermilk,  eggs,  animal  broths,  and  all 
saccharine,  starchy,  and  fatty  constituents  should  be  avoided.  Fresh 
meats,  game,  poultry,  and  fish,  without  butter  or  fat,  are  admissible 
if  the  stomach  is  equal  to  their  digestion.  The  most  rapid  progress 
can  be  made  by  adhering  to  an  exclusive  diet  of  milk,  and,  as  there  is 
complete  anorexia,  this  is  usually  not  difilcult.  The  hyperaemia  of  the 
duodenal  mucous  membrane  is  relieved  by  saline  laxatives,  by  the  Sara- 
toga, Carlsbad,  or  Yichy  waters,  by  Rochelle  salts,  but  especially  by 
phosphate  of  soda,  which  should  be  given  in  drachm-doses  about  four 
times  a  day.  Other  remedies,  acting  similarly,  are  sulphate  of  mag- 
nesia and  bitartrate  of  potassa.  The  general  principle  is  to  use  reme- 
dies which  will  promote  an  outward  osmotic  flow,  and  thus  relieve  the 
congestion  and  oedema  of  the  mucous  membrane.  Mercurials  are  not 
beneficial.  Active  cholagogues,  as  the  resin  of  podophyllin,  rhubarb, 
aloes,  etc.,  are  to  be  avoided  on  account  of  the  irritation  which  they 
induce.  To  rouse  the  liver — a  favorite  phrase — is  out  of  place  here, 
since  the  obstacles  to  the  outflow  of  bile  are  merely  mechanical. 
When  malarial  infection  coexists,  quinia  is  indispensable  to  restore 
health.  Without  any  complication  of  malaria,  quinia  has  a  good 
effect,  and  hastens  the  disappearance  of  the  jaundice.  When  the  bile 
enters  the  intestine  and  the  intestinal  digestion  is  restored,  the  jaundice 


ILEO-COLITIS.  67 

may  still  linger.     Diui-etics  and  purgatives  may  then  be  employed  to 
remove  the  last  traces  of  bile-pigment. 


ILEITIS— ILEO-COLITIS— CATARRH  OF  THE  ILIUM  AND  OF  THE 
ILIUM  AND  COLON.  ACUTE  DIARRHCGA|  CHRONIC  DIAR- 
RHCEA. 

Definition. — Ileitis  is  a  catarrh  of  the  ilium,  either,  acute  or  chronic  ; 
ileo-colitis  is  a  catarrh  involving  both  parts — the  whole  extent  of  the 
ilium  and  the  caecum  and  ascending  colon.  This  may  also  be  either 
acute  or  chronic.  The  disease  is  frequently  denominated  diarrhoea, 
from  a  single  symptom. 

Causes. — The  causes  already  given  for  other  forms  of  intestinal 
catarrh  are  equally  true  of  this  form.  The  two  great  factors  are  im- 
proper and  indigestible  food  and  the  summer  temperature.  An  attack 
may  be  brought  on  by  exposure  to  cold  and  damp  air  when  in  a  per- 
spiring state.  The  sudden  arrest  of  cutaneous  transpiration  precipi- 
tates a  vicarious  duty  on  the  mucous  membrane,  with  the  eifect  to 
induce  a  general  hyperaemia  of  the  ilium  and  colon.  As  respects  chil- 
dren, the  causes  in  operation  to  produce  ileo-colitis  are  the  same  as 
those  which  bring  on  cholera  infantum. 

Pathological  Anatomy. — In  this  variety  of  intestinal  catarrh,  the 
morbid  anatomy  has  the  special  feature  of  enlargement  of  the  agmi- 
nated  patches,  which  are  most  abundant  and  most  highly  developed  in 
the  lower  ilium.  The  condition  of  the  epithelium,  of  the  villi,  and  of 
the  glands,  has  been  described.  Sufficient  emphasis  has,  probably,  not 
been  put  on  the  tendency  of  the  swollen  glands  to  ulcerate.  In  the 
acute  cases  the  orifices  of  the  solitary  glands  are  here  and  there 
eroded  ;  but  in  the  chronic  cases  considerable  ulcers  form.  These 
changes  are  different  in  character  and  very  different  in  extent  from 
those  which  take  place  in  typhoid. 

Symptoms. — The  acute  form  of  ileitis  or  ileo-colitis  sets  in  with 
some  chilliness  and  general  malaise,  followed  by  feverishness.  Pain 
in  the  abdomen,  usually  about  the  umbilicus,  is  felt,  and  then  loose 
evacuations  begin.  The  number  of  stools  each  day  varies  with  the 
character  of  food  and  the  extent  of  the  disease,  especially  in  the  colon. 
It  would  be  a  mistake  to  suppose  that  the  diarrhoea  is  due  solely  to  an 
irritation  of  the  affected  jDortions  of  the  mucous  membrane,  by  the  par- 
ticles of  aliment  reaching  them.  Considerable  transudation  occurs  as 
one  result  of  the  hyperaemia  :  cast-off  epithelium,  young  cells,  and  mi- 
nute sloughs  mix  with  the  serum,  and  constitute  no  small  part  of  the 
stools  discharged.  Besides,  the  chyle  imperfectly  prepared  for  absorp- 
tion, and  hurried  down  the  canal  by  the  increased  peristalsis,  and  the 
fatty,  starchy,  and  saccharine  constituents  of  the  food,  fermenting  in- 
stead of  digesting,  unite  to  form  the  liquid  discharges  characteristic  of 


68  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

ileo-colitis.  As  iniglit  be  exjjected,  there  is  little  fecal  matter  proper, 
and  the  stools  have  a  yellow  or  greenish-yellow  color,  and,  if  the 
evacuations  have  been  very  copious,  they  may  be  whitish,  like  the 
"  rice-water  "  discharges.  In  children  the  stools  have  a  somewhat  dif- 
ferent character,  owing  to  the  presence  of  casein,  which  presents  an 
appearance  of  putty,  or  the  casein  occurs  in  small,  irregular  masses. 
Very  often  the  stools  have  a  bright-green  color,  or  become  green  on 
exposure.  Just  -before  the  evacuation,  considerable  pain  is  experi- 
enced, and,  in  children,  nausea  and  vomiting  also.  The  pain  is  usually 
increased  by  pressure,  and  soreness  is  developed  at  any  time  by  deep 
pressure.  As  gases  are  freely  generated  in  food  decompositions,  the 
intestines  are  often  suddenly  distended,  giving  rise  to  pains  as  of  flatu- 
lent colic.  Borborygmi  are  more  or  less  present.  It  is  a  curious  fact 
that  mental  depression  is  a  very  constant  condition  in  cases  of  ileo- 
colitis, when  there  is  abundant  production  of  gas.  The  digestion  and 
assimilation  of  food  being  almost  arrested,  and  great  waste  taking 
place  by  the  intestinal  mucous  membrane,  it  is  obvious  that  the  organ- 
ism must  lose  ground  rapidly.  The  subcutaneous  fat  disappears  ; 
the  muscles  shrink  and  lose  their  contractile  energy  ;  the  skin  becomes 
dry,  sallow,  and  wrinkled  ;  the  action  of  the  heart  is  weak,  the  pulse 
small  and  feeble  ;  the  urine  is  acid,  high-colored,  and  burning.  Chil- 
dren affected  with  summer  diarrhoea,  and  having  from  three  to  six 
evacuations  a  day,  and  vomiting  occasionally,  rapidly  emaciate,  are 
reduced  to  a  skeleton  in  fact.  In  the  adult  the  chronic  form  is  known 
as  "  chronic  diarrhoea,"  in  which,  as  is  well  known,  the  wasting  of  the 
tissues  of  the  body  proceeds  to  the  lowest  point. 

Course,  Duration,  and  Termination. — In  the  simplest  cases  of  catarrh 
of  the  intestine,  due  merely  to  an  unusual  accumulation  of  fseces — crap- 
ulous diarrhoea — the  looseness  of  the  bowels  is  conservative,  an  effort 
of  nature  to  be  encouraged  rather  than  restrained.  In  mild,  uncompli- 
cated cases  the  tendency  is  to  recovery  in  a  few  days,  but  in  the  severe 
cases  the  duration  may  be  several  weeks.  In  the  chronic  form  the 
duration  is  indefinite.  The  acute  runs  insensibly  into  the  chronic  form, 
and  there  is  no  well-marked  distinction,  except  the  element  of  time. 

Diagnosis. — The  distinctions  to  be  made  are  between  duodenal  ca- 
tarrh and  catarrh  of  the  rectum  (proctitis).  In  children,  ileo-colitis  is 
to  be  distinguished  from  cholera  infantum.  In  duodenal  catarrh  there 
is  little  or  no  diarrhoea,  and  jaundice  appears  in  a  few  days,  symptoms 
entirely  different  from  ileo-colitis.  In  proctitis  the  stools  may  be  nor- 
mal, or  occur  as  scybala.  There  are  straining,  heat,  and  irritation  about 
the  rectum,  and  the  discharge  of  mucus,  and  mucus  and  blood.  In 
children,  ileo-colitis  is  frequently  mistaken  for  and  called  cholera  in- 
fantum. The  latter  is  a  disease  of  sudden  onset,  characterized  by 
choleriform  symptoms  and  a  duration  of  a  few  days  or  few  hours  only. 
The  character  of  the  discharges  is  essentially  different ;  in  ileo-colitis 


TYPHLITIS.  69 

they  contain  casein,  yellowish  or  greenish  liquid  matter,  spinach-colored 
masses  ;  whereas,  in  cholera  infantum,  they  are  serous  in  character, 
colorless,  like  the  so-called  rice-water  evacuations,  and  do  not  leave 
anything  but  a  stain  on  the  napkin. 

Prognosis. — In  acute  diarrhoea,  under  good  hygienic  conditions,  the 
prognosis  is  favorable.  In  children,  summer  diarrhoea  is  amenable  to 
treatment  or  not,  according  to  the  condition  in  life,  and  the  ability  of 
parents  to  provide  the  necessary  means.  When  ileo-colitis  has  become 
chronic,  and  is  not  readily  amenable  to  the  treatment,  the  prognosis  is 
grave.  In  adults,  for  chronic  diarrhoea,  which  has  long  existed,  the 
prognosis  must  be  guarded. 

Treatment. — In  simple  acute  catarrh  relief  is  afforded  by  a  pill  of 
opiu.m  and  camphor.  When  the  evacuations  are  numerous  and  profuse 
— summer  diarrhoea,  for  example — the  most  efficient  treatment  is  the 
combination  of  a  mineral  acid  (muriatic  or  sulphuric)  with  tincture  of 
opium.  Carefully  managed,  the  same  remedies  may  be  administered 
to  infants.  Sometimes  alkalies  agree  better.  Sodium  bicarbonate 
can  be  given  with  or  without  bismuth  in  chalk- mixture.  Alkalies, 
however,  merely  neutralize  acids,  but  the  mineral  acids  check  the  fer- 
mentation on  which  the  production  of  acid  depends.  When  the  dis- 
charges are  greenish  ("  chopped  spinach  "),  the  combination  of  arsenic 
and  opium  is  highly  efficient — for  example,  one  drop  of  Fowler's  solu- 
tion, and  one  or  two  drops  of  the  deodorized  tincture  of  opium.  When 
there  ai'e  retained  matters,  the  presence  of  which  excites  irritation,  an 
emulsion  of  castor-oil,  with  two  or  three  drops  of  turpentine  and  some 
tincture  of  opium,  is  very  advantageous.  In  the  more  chronic  cases,  or 
after  the  acute  symptoms  have  subsided,  sulphate  of  copper  with  a 
little  opium  is  an  admirable  remedy — from  one  thirtieth  to  one  twelfth 
of  a  grain  of  copper  sulphate,  and  one  fortieth  to  one  sixth  of  a  grain 
of  morphia,  according  to  the  age  of  the  subject.  Other  astringents, 
metallic  and  vegetable,  may  be  employed  under  the  same  circum- 
stances. For  children,  bismuth  is  probably  the  best  astringent.  Regu- 
lation of  the  diet  is  even  more  important  than  the  use  of  medicines. 
The  starchy,  fatty,  and  saccharine  articles  of  food  are  highly  objec- 
tionable, and  should  be  omitted  entirely,  as  already  advised.  The 
same  plan  of  diet  suggested  in  previous  articles  is  applicable  here,  and 
need  not,  therefore,  be  repeated. 


TYPHLITIS.— INFLAMMATION    OF    THE   CiE  CUM.— CATARRH  OF 

THE   CECUM. 

Definition. — The  term  typhlitis  is  restricted  to  an  inflammation  of 
the  caecum  and  its  appendix.  Perityphlitis  is  an  inflammation  taking 
place  in  the  loose  connective  tissue  on  which  the  caecum  rests.  Al- 
though the  seat  of  the  lesion  and  its  nature  are  very  different,  it  is 


70  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

necessary,  because  of  their  intimate  relations,  to  consider  tbem  to- 
gether. 

Causes. — Besides  the  causes  of  catarrh  of  the  intestines  already  suf- 
ficiently set  forth,  there  are  special  conditions  affecting  the  csecum. 
The  anatomical  position  of  this  organ  as  a  receptacle  for  the  small  in- 
testine, the  arrangement  of  its  muscular  elements,  the  abundant  folds 
of  mucous  membrane  when  empty,  and  its  immense  capacity  when 
filled,  are  properties  necessary  to  its  function,  but  at  the  same  time 
causes  of  disease. 

Pathological  Anatomy. — Catarrh  of  the  caecum  may  exist  as  a  mere 
catarrhal  affection  of  the  mucous  membrane,  with  the  changes  in  the 
epithelium,  in  the  solitary  glands,  and  in  the  vessels  already  described; 
or  as  a  localized  inflammation,  usually  from  the  presence  of  a  foreign 
body,  terminating  in  ulceration  ;  or  as  an  inflammation  of  the  caecum 
in  general,  with  a  more  intense  action  about  the  ileo-csecal  valve,  and 
implication  with  thickening  of  the  submucous  connective  tissue  causing 
stenosis.  The  second  or  ulcerative  form  of  catarrh  of  the  caecum  will 
be  described  hereafter  under  ulcers  of  the  intestinal  canal.  The  last- 
named  variety  remains  for  consideration.  The  ileo-caecal  valve  being 
more  exposed  to  injury  than  any  other  part  of  the  caecum,  owing  to  its 
position  and  office,  is  more  liable  to  be  invaded  by  disease.  When  a 
catarrh  of  the  caecum  exists,  especially  the  chronic  form,  the  hyperae- 
mia  and  swelling  are  more  decided  in  the  neighborhood  of  the  orifice. 
An  extension  of  the  inflammation  to  the  submucous  layer  occasionally 
takes  place,  the  connective  tissue  undergoes  hyperplasia,  a  permanent 
increase  of  thickness  results,  and  stenosis  is  an  ultimate  effect  of  the 
changes.  It  is  only  in  the  chronic  form  that  such  thickening  and  ste- 
nosis can  occur. 

Symptoms. — There  are  two  forms  of  catarrh  of  the  caecum — the 
acute  and  chronic.  Of  the  acute  variety,  there  are  various  grades  in 
the  severity  of  the  cases,  but  two  are  sufficiently  defined  to  require 
attention — the  mild  and  the  severe.  In  the  mild  cases,  uneasiness, 
followed  by  pain  and  soreness,  is  felt  in  the  right  iliac  region,  extend- 
ing up  along  the  course  of  the  ascending  colon.  On  palpation,  ten- 
derness is  found  to  exist  in  this  region  and  laterally  just  above  the 
crest  of  the  ilium.  The  more  decided  the  pressure,  the  more  distinct 
the  pain.  Early,  and  before  the  inflammation  has  extended  beyond  the 
mucous  layer  of  the  caecum,  the  decubitus  and  the  sitting  posture  are 
characteristic — the  body  is  turned  toward  the  right  side,  and  is  flexed 
somewhat  to  relax  the  muscles  on  the  right  lateral  plane.  Additional 
soreness  is  experienced  when  the  body  is  held  erect,  or  straightened 
out  in  bed.  With  the  first  symptoms  there  may  be  some  accumulation 
of  faeces,  and  the  caecum  and  ascending  colon  may  be  distinctly  bulging 
and  prominent,  so  that  they  may  be  recognized  on  inspection  ;  but  in 
the  mild  cases  there  is  no  impaction,  properly  speaking,  but  on  careful 


TYPHLITIS.  71 

palpation  the  outline  of  the  bo^'el  can  be  made  out,  feeling  rather 
soft  and  dough-like.  The  bowels  are  usually  constipated,  for  catarrh 
of  the  csecum  seems  to  affect  the  muscularis,  impairing  its  contractile 
energy,  or  there  may  be  an  appearance  of  relaxation  by  reason  of  an 
accumulation  in  the  sacculated  periphery  of  the  bowel — leaving  a  cen- 
tral cavity  along  which  the  liquid  contents  of  the  small  intestines  may 
pass.  The  author  has  seen  several  examples  of  this,  and  so  important 
is  the  recognition  of  the  condition  that  he  now  desii'es  to  emphasize 
the  fact.  During  the  development  of  these  local  symptoms,  the  sys- 
tem partakes  in  the  disturbance.  The  attack  sets  in  -with  general 
malaise,  some  feverishness,  a  coated  tongue,  loss  of  appetite,  nausea, 
and  not  unfrequently  vomiting.  In  the  severe  cases,  the  symptoms 
are  increased  in  severity  in  all  du-ections.  The  local  pain,  tenderness, 
and  swelling  are  greater,  there  are  impaction  of  faeces  and  no  move- 
ment. There  are  decided  fever,  considerable  restlessness,  nausea,  and 
vomiting.  The  vomited  matters  consist  at  first  of  the  contents  of  the 
stomach,  then  of  the  duodenum  with  much  bilious  matter,  and  ulti- 
mately, if  the  impaction  persist,  of  matter  that  has  somewhat  the  odor 
of  faces.  With  the  development  of  the  case,  there  occurs  great  de- 
pression of  the  powers  of  life,  the  face  becomes  pinched  and  anxious, 
the  skin  covered  by  a  clammy  sweat,  the  pulse  small  and  rapid,  the 
action  of  the  heart  weak.  Peritonitis  is  finally  developed  by  contigu- 
ity of  tissue,  or  by  the  bowel  giving  way  at  some  point,  weakened  by 
ulceration.     The  subsequent  history  is  then  the  history  of  peritonitis. 

In  the  chronic  cases,  which  may  succeed  to  the  mild  acute,  or, 
"which  is  much  more  common,  develop  slowly  by  the  operation  of  the 
ordinary  causes  of  intestinal  catarrh,  the  symptoms  are  those  of  intes- 
tinal indigestion.  There  is  uneasiness  in  the  region  of  the  ileo-cgecal 
valve,  flatus  is  felt  passing  the  orifice,  and  the  patient  is  often  con- 
scious of  the  difference  in  density,  whether  gas,  liquid,  or  solid,  of  the 
materials  passing  the  orifice.  The  bowels  are  confined  and  rather  dif- 
ficult to  move.  When  the  actions  are  free,  semi-solid,  and  unirritating, 
the  patient  has  a  keen  sense  of  relief.  Rarely,  on  careful  palpation, 
induration,  not  hard  like  that  of  scu-rhus,  but  doughy,  can  be  made 
out.  A  compai-atively  empty  state  of  the  large  intestine  and  disten- 
tion of  the  small  intestines  can  usually  be  ascertained  ;  in  that  event 
the  lateral  portions  of  the  abdomen  are  rather  flat,  and  the  central 
part  around  the  umbilicus  is  prominent. 

Course,  Duration,  and  Termination. — The  mild  form  of  acute  ca- 
tarrh of  the  caecum,  if  properly  managed,  is  readily  cured  in  a  week 
or  two.  The  severe  form  may  terminate  by  acute  peritonitis  within  a 
week,  or  be  relieved,  and  all  pain  and  tenderness  subside,  -vvithin  two 
or  three  weeks.  Very  frequently  entire  recovery  does  not  ensue,  but 
the  case  passes  into  chronic  catarrh,  the  duration  of  which  is  very  in- 
definite. 


72  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

Diagnosis. — It  is  often  extremely  difficult  to  distinguish  typhlitis 
from  perityphlitis  or  frora  occlusion  of  the  bowel  by  other  kinds  of 
obstruction.  The  points  of  difference  between  typhlitis  and  perity- 
phlitis can  be  better  understood  after  the  study  of  the  latter,  and  are 
therefore  reserved.  Typhlitis  in  the  mild  form  is  distinguished  from 
other  affections  of  the  bowel  by  the  local  pain  and  soreness,  by  the 
fullness  without  impaction  ;  in  the  severe  form,  the  symptoms  of  ob- 
struction are  the  same  as  in  other  kinds  of  occlusion,  but  the  local 
pain  and  the  distinct  enlargement  of  the  bowel  indicate  the  existence 
of  an  inflammation  and  fecal  obstruction  of  the  csecum.  In  these  af- 
fections, the  decubitus  of  the  patient  is  an  important  aid  to  diagnosis. 
Chronic  catarrh  of  the  caecum  is  recognized  by  the  locality  of  the  dis- 
tress. As  cancer  of  the  csecum  behaves  in  the  same  way  in  the  early 
stage  of  its  formation,  there  may  be  no  means  of  differentiating  ;  but, 
in  the  progress  of  the  case,  the  growth  of  a  nodulated  tumor,  the  pro- 
gressive increase  in  the  pain  and  obstruction,  and  the  develoi^ment  of 
a  cachexia,  are  sufficient  to  indicate  the  nature  of  the  affection. 

Prognosis. — In  the  simple  form  the  prognosis  is  favorable  ;  in  the 
severe  form  it  is  grave,  although  recovery  will  ensue  in  a  large  pro- 
portion of  the  cases  if  the  management  is  judicious.  In  the  chronic 
form,  when  the  connective  tissue  has  become  thickened,  the  prognosis 
as  to  cure  is  unfavorable. 

.  Treatment.— In  the  treatment  of  acute  typhlitis  all  active  purga- 
tives must  be  avoided.  If  there  is  but  little  feverishness,  and  the 
local  tenderness  is  slight,  saline  laxatives  may  be  administered  from 
the  beginning,  in  small  doses  at  short  intervals,  to  induce  liquefaction 
of  the  contents  of  the  bowel.  The  hyperaemia  is  lessened  by  the  same 
means.  When  free  discharges  are  obtained  in  this  way,  the  canal 
should  be  kept  quiet  with  opium  for  a  few  days.  The  most  efficient 
and,  at  the  same  time,  safe  laxative  is  sulphate  of  magnesia.  It  is  a 
curious  fact  that  this  salt  will  be  retained  when  other  salines  are  re- 
jected by  vomiting.  Rochelle  salts  may  be  used  as  a  substitute  when 
Epsom  salts  is  not  suitable.  Different  management  is  required  in  cases 
of  typhlitis  with  impaction  and  arrest  of  the  intestinal  movements.  If 
there  be  fever  and  much  tenderness,  no  attempt  should  be  made  to 
relieve  the  bowels  by  purgatives  of  any  kind.  It  is  in  this  condition 
of  affairs  that  opium  in  some  form,  especially  in  the  form  of  the  hypo- 
dermatic injection  of  morphia,  is  so  serviceable.  The  patient  should 
be  kept  thoroughly  under  the  influence  of  the  narcotic.  It  is  better  to 
combine  atropia  with  the  morphia,  for  greater  security  and  increased 
therapeutical  power.  No  absolute  rule  for  quantity  can  be  laid  down, 
but  the  decided  effects  of  morphia,  as  shown  in  the  state  of  the  pupil, 
the  pulse,  the  respirations,  and  the  somnolence,  should  be  steadily 
maintained.  The  fullest  curative  power  of  morphia  is  obtained  from 
a  quantity  strictly  within  the  limits  of  safety,  and  hence  no  risk  need 


TYPHLITIS.  Y3 

be  had  to  obtain  the  best  results.     As  a  guide  to  the  administration,  it 
may  be  stated  that  one  fourth  of  a  grain  of  morphia  and  yj-g-  grain  of 
atropia  is  enough  for  the  first  dose  in  an  adult,  and  subsequently  one 
eighth  of  a  grain  of  morphia  and  t^  grain  of  atropia  every  four,  six, 
or  eight  hours  according  to  the  effect.     If  there  be  any  reason,  moral 
or  physical,   which  prevents  the  hypodermatic  administration  being- 
employed,  the  next  best  mode  is  the  rectal  injection  of  the  tincture  of 
opium.     As  respects  the  quantity,  the  rule  above  given  is  proper  ;  it  is 
the  degree  and  constancy  of  the  effect  which  determine  the  amount. 
If  the  rectal  injection  is  objected  to,  or  the  organ  is  intolerant,  opium 
must  be  administered  by  the  stomach.     The  best  preparation  is  the 
deodorized  tincture,  and,  to  secure  uniformity  in  action,  the  preparation 
made  after  an  essay  of  the  opium  is  altogether  preferable.     This  cor- 
responds in  strength  to  laudanum  :  sixty  drops  may  be  the  first  dose, 
and  twenty  drops  every  two,  three,  or  four  hours  succeeding^  the  quan- 
tity to  be  determined  by  the  effects,  as  already  insisted  upon.     The- 
administration  of  the  opium  is  to  be  continued  until  the  bowels  are 
moved  spontaneously,  or  until  the  inflammatory  action — the  fever  and 
local  tenderness — subsides.    The  effects  may  be  maintained  for  several 
days,  for  a  "week  or  more.     As  soon  as  the  tenderness  subsides,  the 
saline  laxative  may  be  then  given,  in  the  cautious  way  already  advised 
— a  teaspoonful  of  Epsom  salts  in  two  ounces  of  water  every  three 
hours.     With  the  subsidence  of  the  local  tenderness  and  heat,  the 
quantity  of  opium  can  be  slowly  reduced  and  the  interval  between  the 
doses  lengthened.     If  the  vomiting  be  pei'sistent,  it  may  be  relieved 
by  milk  and  lime-water  (three  parts  to  one),  carbolic  acid   (gr.  ss.  in 
cherry-laurel  water),  hydrocyanic  acid  (tti  iij),  iced  champagne,  pellets 
of  ice,  etc.,  but  when  the  hypodermic  injection  is  practiced  vomiting  is 
a  much  less  pronounced  symptom.    In  robust  subjects,  in  all  cases,  not 
characterized  by  great  debility,  leeches  should  be  applied  at  the  seat 
of  tenderness,  and  in  numbers  according  to  the  state  of  the  patient — 
from  two  to  ten  to  be  allowed  to  fill  and  drop  off,  and  the  bleeding  be 
then  arrested.     Good  effects  are  obtained  from  coiinter-irritation  by 
mustard,  followed  by  fomentations  of  turjDentine,  or  turpentine  stupes, 
and  hot  poultices,  "when  heat  applications  are  useful.     According  to 
the  author's  observation  in  these  cases,  the  external  application  of  ice 
— in  the  form  of  an  ice-bag — is  more  efficient  than  warm  applications. 
In  the  severe  cases  of  typhlitis,  when  the  time  has  arrived  for  attempts 
to  remove  the  impaction,  the  action  of  the  saline  laxative  may  be  aided 
by  irrigation  of  the  bowel.     It  is  now  known  that  by  this  method  the 
bowel  may  be  filled  with  fluid  up  to  the  ileo-cascal  valve.    Accordingly, 
repeated  efforts  by  enemata  of   warm '  soapsuds  should  be  made   to 
soften  the  masses  of  hardened  faeces  which  so  effectually  block  the 
canal.     The  use  of  a  long  rectal  tube  to  convey  the  fluid  beyond  the 
sigmoid  flexure  facilitates  the  operation  materially.     If  impaction  has 


Y4:  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

existed  for  several  days,  care  must  be  used  in  distending  the  bowel, 
for  it  may  yield  to  tbe  pressure,  softened  it  may  be  by  an  inflammatory 
process  involving  all  tbe  layers. 

INFLAMMATION    OF    THE    APPENDIX    VERMIFORMIS.  —  The 

usual  cause  of  inflammation  of  the  appendix  is  the  lodgment  of  an 
intestinal  concretion,  grape-seed,  or  other  foreign  body.*  Cases  of 
inflammation,  apparently  catarrhal,  do,  however,  rarely  occur,  and  very 
serious  symptoms  quickly  arise  by  extension  of  the  disease  to  the  peri- 
toneal layer.  The  symptoms  are  the  same  as  those  of  the  severe  form 
of  typhlitis,  with  some  important  exceptions  to  be  presently  detailed. 
The  appendix  differs  from  the  csecum  in  that  it  has  an  entire  perito- 
neal investment,  and  in  that  it  is  free  except  its  point  of  connection 
with  the  caecum.  In  some  subjects  the  appendix  is  two  inches  in 
length,  and  hence  dips  down  into  the  iliac  region  to  the  pelvis,  and 
reaches  almost  or  quite  to  the  bladder.  When,  therefore,  an  inflam- 
matory process  occurs  in  it,  the  tenderness  and  pain  are  felt  in  the  iliac 
region  as  low  down  as  Poupart's  ligament,  and  not  in  the  csecum. 
When  typhlitis  exists,  the  aj^pendix  becomes  involved,  but  death  may 
and  does  frequently  follow  from  disease  of  the  appendix,  without  the 
caecum  being  implicated.  When,  therefore,  this  form  of  typhlitis 
occurs,  besides  the  symptoms  abeacly  set  forth,  there  is  pain  in  the 
groin,  extending  down  the  course  of  the  anterior  crural,  and  through 
the  hip.  The  tenderness  is  usually  exquisite,  and  the  slightest  attempt 
at  palpation  gives  the  patient  great  dread.  The  thigh  is  flexed  on  the 
pelvis,  and  all  attempts  to  extend  it  cause  great  suffering.  There  is 
no  fecal  tumor  such  as  is  found  in  typhlitis  with  impaction,  and  the 
bowels  are  not  affected,  but  all  intestinal  movements,  as  the  passing  of 
gas  through  the  ilio-caecal  valve,  cause  pain.  Peritonitis,  much  more 
readily  than  in  affections  of  the  caecum,  occurs  in  inflammation  of  the 
appendix.  It  is  often  entirely  local,  adhesions  form,  and  the  morbid 
action  is  cut  off  from  the  general  cavity  of  the  abdomen.  This  is  one 
of  the  modes  by  which  fecal  abscesses  are  formed.  This  subject  and 
peritonitis  are  properly  topics  for  future  consideration. 

PERITYPHLITIS.— As  the  term  indicates,  this  is  an  inflammation  of 
the  tissue  about  the  csecum — really,  of  the  connective  tissue  in  which 
the  csecum  is  in  part  imbedded.  This  may  arise  spontaneously — an 
inflammation  of  the  connective  tissue — ^by  the  ordinary  causes  of  such 
inflammation,  especially  trauma.  It  may  be  caused  by  the  extension 
of  inflammation  from  the  caecum,  by  perforation  of  the  caecum.  Its 
special  tendency  is  to  suppuration.     When  well  developed  there  is  a 

*  See  cases  reported  by  the  author  in  his  paper  on  typhlitis,  in  the  "  American  Jour- 
nal of  Medical  Sciences,"  October,  1866,  p.  351. 


PROCTITIS.  Y5 

hard,  brawny  swelling  felt  above  the  crest  of  the  ilium,  extending 
back  into  the  lumbar  region.  There  is  not  usually  acute  pain,  but  a 
feeling  of  weight,  soreness,  with  paroxysms  of  subacute  pain,  extend- 
ing into  the  hip,  thigh,  and  abdomen.  There  is  no  necessary  interfer- 
ence with  the  bowel,  unless  typhlitis  and  perityphlitis  coexist.  The 
development  of  the  swelling  is  comparatively  slow,  but  it  attains  con- 
siderable dimensions.  Suppuration  is  preceded  by  an  increase  of  the 
local  distress  ;  when  it  has  actually  taken  place,  the  tension  and  throb- 
bing diminish  for  a  time,  to  increase  again  as  the  pus  nears  the  sur- 
face. The  formation  of  matter  is  attended  by  the  usual  constitutional 
symptoms. 

The  treatment  of  perityphlitis  is  the  same  as  that  of  typhlitis,  except 
as  regards  the  special  attention  given  to  the  bowels,  and  entirely  the 
same  if  the  two  maladies  coexist.  When  pus  forms  in  perityphlitis, 
and  when  a  sero-purulent  collection  is  formed  by  a  limiting  inflamma- 
tion, in  inflammiation  or  perforation  of  the  appendix,  there  arises  the 
surgical  question  of  an  operation  for  the  evacuation  of  the  matter.  By 
the  use  of  the  aspirator,  the  question  of  suppuration  may  be  early  de- 
termined. It  is  no  doubt  sound  practice  to  pursue  the  method  of  Buck, 
and  procure  the  evacuation  of  pus  by  a  sufiicient  opening  for  free 
drainage.* 

CATARRH  OF   THE  RECTUM.— PROCTITIS  AND  PERIPROCTITIS. 

Definition. — Catarrh  of  the  rectum  is  known  as  proctitis.  In  the 
mild  form  it  is  the  simplest  kind  of  dysentery.  In  the  severe  form,  as 
in  the  caecum,  there  may  be  impaction  of  the  colon  at  and  above  the 
sigmoid  flexure.  The  two  forms  correspond  to  the  same  conditions 
in  the  caecum.  The  analogy  becomes  the  more  complete  by  reason 
of  periproctitis — an  inflammation  of  the  connective  tissue  about  the 
rectum. 

Causes.  —  Proctitis  arises  chiefly  from  constipation.  Prolonged 
retention  of  hardened  fseces  sets  up  an  irritation  for  their  expulsion. 
It  is  also  caused  by  cold  and  dampness  combined,  especially  sitting  on 
the  ground  while  in  a  perspiring  state.  Distention  of  the  hsemor- 
rhoidal  vessels,  by  obstructive  disease  of  the  liver,  as  in  cirrhosis,  is  an 
occasional  cause,  but  the  disease  then  is  quite  masked  by  the  more 
important  results  of  the  cirrhosis.  The  habitual  use  of  stimulating 
enemata  and  of  aloetic  purgatives  is  a  fruitful  source  of  proctitis. 

Pathological  Anatomy. — The  alterations  of  structure  are  the  same 
as  those  already  described. 

Symptoms. — There  are  an  acute  and  chronic  form,  the  symptoms  of 
which  differ  in  degree  merely.     The  acute  variety  exists  in  two  forms, 

*  "  New  York  Medical  Journal,"  vol.  ii,  p.  38.  Numerous  cases  have  been  reported 
of  some  foreign  body  discharged  by  a  fecal  abscess.     Hence,  the  need  of  a  free  opening. 


Y6  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

the  mild  and  severe.  In  the  mild  form  of  proctitis,  the  patient  experi- 
ences a  sense  of  uneasiness  in  the  rectum — a  burning,  with  desire  to 
go  to  stool.  There  is  much  straining,  and  only  mucus  passes.  The 
sphincter  ani  is  in  a  constant  state  of  spasm.  Immediately  after  the 
passage  of  some  mucus,  there  is  felt  considerable  burning  pain,  and  a 
sensation  as  if  something  remained,  so  that  the  patient  returns  again 
and  again  to  the  close-stool,  and  as  before  passes  only  some  mucus  or 
mucus  mixed  with  blood.  This  condition  is  called  tenesmus.  The 
pain  radiates  from  the  rectum  to  the  hips  and  back,  and  a  feeling  of 
depression  and  anxiety,  and  often  of  nausea,  accompanies  it.  The 
colon  is  distended  above  the  sigmoid  flexure,  but  only  some  hard, 
roundish  masses  of  freces,  known  as  scybala,  descend  occasionally.  In 
the  severe  f  onn  all  of  these  symptoms  are  intensified,  the  pain  is  very 
acute,  intensely  burning,  and  widely  diffused.  The  straining  is  violent, 
and  prolapse  of  the  mucous  membrane  takes  place,  the  sphincter  ani 
closes  over  it  spasmodically  and  the  protruding  portion  becomes  exces- 
sively painful,  purplish,  and  bleeding.  The  mucus  discharged  is  mixed 
with  blood,  and  sometimes  considerable  haemorrhage  occurs  in  conse- 
quence of  the  yielding  of  a  vessel.  The  colon  aboA- e  is  impacted  with 
hardened  faeces,  and  its  outlines  can  be  distinctly  traced  by  palpation. 
In  the  severe  form  of  proctitis  there  is  usually  some  constitutional  dis- 
turbance—^some  feverishness,  headache,  and  general  muscular  soreness. 
The  neighboring  organs  sympathize  with  the  rectum.  In  the  female, 
the  menstrual  flow  may  occur,  and,  in  both  male  and  female,  strangury 
comes  on,  and  with  the  straining  at  stool  there  is  simultaneous  straining 
at  the  passage  of  urine.  The  long-continued  distention  of  the  colon 
induces  an  in'itation  of  the  mucous  membrane  ;  a  catarrhal  process  is 
set  up  for  the  expulsion  of  the  accumulated  faeces,  but  the  muscular 
layer,  over-distended,  becomes  paretic  and  is  incapable  of  any  energetic 
action  ;  the  inflammation  extends  and  ultimately  the  peritoneum  be- 
comes involved.  The  progress  of  these  structural  changes  is  mani- 
fested objectively  by  an  increasing  tenderness  along  the  track  of  the 
descending  colon,  and  finally  by  an  extension  of  the  inflammation  to 
the  adjacent  connective  tissue,  the  formation  of  a  tumor,  terminating 
in  an  abscess.  In  the  cavity  of  the  pelvis  a  similar  j^rocess  may  take 
place,  the  inflammation  of  the  mucous  membrane  extending  by  con- 
tiguity to  the  layers  of  the  bowel  successively,  and  at  length  involving 
the  neighboring  connective  tissue.  The  chronic  form  of  proctitis  pre- 
sents nearly  the  same  features.  There  are  usually  accumulations  of 
scybala  in  the  sacculated  periphery  of  the  colon,  but  the  bowels  may 
be  confined  or  relaxed.  The  relaxed  stools  contain  a  good  deal  of 
mucus,  and  are  highly  offensive  by  reason  of  the  decompositions  which 
have  ensued  in  the  descent  along  the  colon,  and  the  scybala  are  coated 
with  mucus.  Instead  of  ordinary  mucus,  the  matter  now  discharged 
contains  purulent  elements — muco-pus — and  ultimately  becomes  en- 


PROCTITIS.  77 

tirely  purulent  in  the  rectum.  Ulcerations  ensue,  sloughs  separate, 
and  hence  the  stools  contain  the  debris.  The  nerves  become  somewhat 
accustomed  to  the  irritation  of  their  terminal  filaments  in  the  mucous 
membrane,  and  therefore  the  reflex  incitement  to  tenesmus  is  much 
less.  There  are,  therefore,  less  straining,  les^  acute  pain,  but  the  stools 
are  more  unhealthy. 

Course,  Duration,  and  Termination. — The  mild  form  of  catarrh  of 
the  rectum  has  a  natural  tendency  to  cure  in  from  four  to  eight  days. 
The  bowels  act  freely,  the  colon  is  emptied,  and  the  tenesmus  ceases. 
In  the  more  severe  cases,  although  a  spontaneous  cure  may  result,  yet 
there  is  great  danger  of  peritonitis,  or  periproctitis  and  abscess. 
When  the  latter  forms,  it  tends  to  discharge  alongside  the  rectum,  re- 
sulting in  fistula  usually,  or  into  the  vagina  or  neighboring  organs, 
forming  various  kinds  of  fistulse.  The  duration  of  the  severe  form  is 
determined  largely  by  the  character  of  the  treatment.  The  chronic 
form  is  obstinate,  and  pursues  a  uniform  course  leading  to  extensive 
ulceration,  sometimes  perforation  and  peritonitis,  or  cicatrization  and 
permanent  encroachment  on  the  lulnen  of  the  bowel.  Thrombosis  of 
the  inferior  hsemorrhoidal  veins,  with  subsequent  formation  of  hepatic 
abscess  by  deposit  of  emboli,  is  a  not  uncommon  result.  These 
changes  are  all  promoted  by  the  fermentations  occurring  in  the  rec- 
tum, the  products  of  which  are  highly  irritating  and  offensive. 

Diagnosis. — The  symptoms  of  acute  proctitis  are  so  distinctive 
that  the  diagnosis  is  made  by  them.  In  women,  irritation  of  the  rec- 
tum and  tenesmus  are  produced  by  retroversion,  especially  of  the  gravid 
uterus.  A  vaginal  exploration  may  be  necessary  to  determine  the  po- 
sition of  the  womb  :  if  the  symptoms  persist  after  the  malposition  is 
rectified,  then  it  may  be  justly  assumed  that  disease  exists  in  the  rec- 
tum. In  women,  the  eversion  of  the  rectum  through  the  sphincter 
ani  is  so  readily  performed  that  the  nature  of  the  case  may  be  deter- 
mined by  ocular  inspection.  Exploration  of  the  rectum  may  be  neces- 
sary to  differentiate  between  ulcer  of  the  rectum  and  chronic  proctitis. 
Many  of  the  symptoms  may  be  due  to  haemorrhoids  ;  an  examination 
should  be  instituted  whenever  doubt  exists. 

Prognosis. — A  favorable  termination  may  be  predicted  in  every 
case  of  acute  proctitis,  unless  implication  of  the  peritoneum,  perfora- 
tion, or  periproctitis  has  occurred.  When  peritonitis  has  arisen,  the 
prognosis  is  extremely  unfavorable  if  it  is  general,  especially  if  from 
perforation,  but  is  less  gloomy  when  limited  by  adhesions.  In  the 
suppuration  which  then  ensues,  the  resources  of  the  organism  are 
severely  tried  ;  in  suppuration  from  periproctitis  low  down,  although 
the  strength  may  be  much  reduced,  a  fatal  result  is  very  rare  ;  but  in 
these  cases  the  local  condition  may  be  a  mere  expression  of  a  dyscrasia, 
as  tuberculosis,  and  they  are  to  be  estimated  accordingly.  In  chronic 
proctitis  the  gravity  of  the  case  is  increased  by  accidental  and  conse- 


Y8  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

quential  complications.  The  existence  of  cirrhosis  is  unfavorable,  as  it 
keeps  up  a  constant  over-fullness  of  the  inferior  haemorrhoidal  veins. 
Obstructive  cardiac  and  pulmonary  diseases  act  in  the  same  way, 
though  not  so  directly.  The  more  changed  the  mucous  membrane  is 
in  structure,  the  more  extensive  and  deep  the  ulcerations,  and,  the 
greater  the  hypertrophy  of  the  muscular  layer,  the  more  serious  the 
case.  A  very  important  complication  is  thrombosis  of  an  haemorrhoidal 
vein,  with  detached  emboli,  and  subsequent  multiple  abscess  of  the 
liver.  When  this  condition  of  things  exists,  the  gravity  of  the  case 
is  vastly  increased. 

Treatment. — Unless  impaction  is  complete,  and  the  peritoneal  lay- 
er of  the  bowel  implicated,  the  first  duty  to  be  done  is  to  empty  the 
colon  of  its  retained  fseces.  It  is  a  most  serious  mistake  in  treating 
acute  catarrh  of  the  rectum  (dysentery),  and  one  frequently  made,  to 
employ  astringents  and  anodynes  with  a  view  to  quiet  the  straining  at 
stool.  When  the  bowels  are  freely  evacuated,  little  remains  to  be 
done  in  the  ordinary  cases.  As  already  indicated,  under  similar  con- 
ditions, there  is  no  laxative  so  safe  and  efficient  as  Epsom  salts.  It 
should  be  given  in  solution  with  dilute  sulphuric  acid —  3  ij  of  sul- 
phate of  magnesia  and  ""1  xx  of  dilute  sulphuric  acid  in  two  ounces 
of  water  every  two  hours  until  the  bowel  is  emptied.  The  straining 
at  stool  and  the  pain  may  be  then  promptly  arrested  by  the  hypoder- 
matic injection  of  morphia,  or  by  enemata  of  tincture  of  opium  in 
starch-mixture,  or  by  opium  in  some  form  by  the  stomach.  In  the 
severe  cases,  the  action  of  Epsom  salts  may  be  aided  by  irrigation  of 
the  bowel.  A  considerable  quantity  of  warm  water  should  be  slowly 
injected,  and  retained  as  long  as  possible  to  soften  the  hardened  faeces, 
and  successive  injections  should  be  practiced  at  short  intervals.  These 
lavements  are  useful  in  allaying  the  excessive  irritability  of  the  mu- 
cous membrane.  Other  salines  may  be  used,  but  none  are  so  effective 
as  the  Epsom  for  this  particular  purpose.  Enemata  of  emollients  may 
be  used  instead  of  hot  water — for  example,  infusion  of  flaxseed,  of 
elm,  of  camomile,  etc. — but  they  are  really  less  efficient,  because  they 
are  less  solvent  of  the  faeces.  Various  purgatives,  notably  castor-oil, 
have  been  used  to  dislodge  the  impacted  faeces,  but  they  do  not  estab- 
lish an  outward  osmotic  flow  to  diminish  congestion  of  the  mucous 
membrane,  which  is  the  important  action  of  the  salines.  In  the  severe 
form  of  proctitis,  in  robust  subjects,  and  even  in  the  weakly,  leeches 
should  be  carefully  applied  around  the  margin  of  the  anus.  If  there 
be  much  tenderness,  an  ice-bag  should  be  applied  over  the  descending 
colon,  or  warm  fomentations,  as  already  advised,  for  corresponding 
states.  In  chronic  catarrh  of  the  rectum,  the  diseased  membrane  can 
be  reached  directly,  and  the  treatment  should,  therefore,  be  largely 
topical.  Solutions  of  tannin  ( 3  j —  3  iv),  of  fluid  extracts  of  hydrastis 
and  rhatany,  and  of  other  vegetable  astringents,  are  effective  local 


CROUPOUS   OR   MEMBRANOUS  ENTERITIS.  79 

applications  if  there  are  no  solutions  of  continuity,  but,  if  ulcerations 
exist,  the  most  efficient  topical  application  is  nitrate -of -silver  solution 
— four  grains  to  a  scruple,  to  an  ounce  of  water.  This  should  be  in- 
jected through  a  tube  carried  up  to  the  sigmoid  flexure.  Next  to  sil- 
ver nitrate  is  the  sulphate  of  copper,  but  this  must  be  used  very  cau- 
tiously. It  is  important  in  these  cases  to  maintain  a  soluble  state  of 
the  bowels.  When  constipation  occurs,  the  congestion  of  the  mucous 
membrane  is  increased,  and  vice  versa.  Hardened  faeces  irritate  in 
passing  the  inflamed  membrane.  As  fermentation,  producing  most 
unhealthy  products,  takes  place  in  the  rectum,  morning  and  evening 
enemata  of  hot  water  should  be  regularly  used.  They  give  great 
comfort,  and  contribute  materially  to  the  cure.  The  wasting  caused 
by  chronic  catan-h  of  the  rectum  demands  the  use  of  the  most  nutri- 
tious food.  Cod-liver  oil  is  highly  serviceable  as  food  and  medicine. 
If  the  digestion  is  feeble,  it  should  be  aided  by  the  mineral  acids  and 
pepsin,  and  by  nux  vomica.  Although  medicines  by  the  stomach  oc- 
cupy an  inferior  position  in  the  treatment  of  this  malady,  excellent 
results  are  obtained  from  the  use  of  minute  doses  of  corrosive  subli- 
mate (one  fortieth  grain  ter  in  die),  or  arsenic  (two  drops  of  Fowler's 
solution  tei'  in  die),  or  of  sulphate  of  copper  (one  sixteenth  grain  ter 
in  die). 

CROUPOUS   OR  MEMBRANOUS  ENTERITIS. 

Deflnition. — By  this  term  is  meant  an  inflammation,  subacute  or 
chronic,  occurring  periodically,  and  characterized  by  the  formation 
and  discharge  of  membranous  shreds  or  casts. 

Causes. — This  is  a  disease  of  adult  life  chiefly  ;  it  is  rare  in  child- 
hood, and  does  not  appear  after  forty-five.  The  female  sex  is  more 
liable  than  the  male  ;  and  nervous,  hysterical,  and  hypochondriacal 
subjects  are  more  subject  to  it  than  are  other  types.  A  peculiar  state 
of  the  nervous  system  seems  necessary  to  its  production.  Membra- 
nous enteritis  occurs  by  extension  of  the  diphtheritic  process  down- 
ward, and  false  membrane  also  forms  in  infective  dysentery,  but  the 
disease  under  consideration  is  a  distinct  affection.  It  has  been  attrib- 
uted to  the  ordinary  causes  of  catarrh  of  the  intestines — especially  to 
irritants,  as  drastic  purgatives,  coarse  food,  etc. — but  such  agencies  can 
act  only  as  exciting  causes. 

Pathological  Anatomy. — Besides  the  exudation  of  diphtheria  and 
of  infective  dysentery,  deposits  of  a  white  or  grayish-white  color, 
flaky  or  membranous,  and  firmly  adherent,  have  been  found  on  the 
mucous  membrane  of  the  ilium  and  colon.  Occurring  first  in  iso- 
lated patches,  the  membrane  extends  laterally  along  the  mucous  folds 
in  the  small  intestine,  and  in  the  colon  upon  the  ileo-caecal  valve 
and  the  folds  of  the  sigmoid  flexure  (Leube).  In  other  cases  (Sir 
James   Simpson)    papular   and   white  vesicular  eruptions   have   been 


80  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

found,  but  no  flaky  membrane  or  casts  adherent  to  the  mucous  mem- 
brane. 

The  membrane  as  passed  has  been  carefully  examined  microscopi- 
cally and  chemically  by  Da  Costa,*  whose  memoir  on  this  disease  is 
by  far  the  most  important  contribution  which  has  been  made  to  our 
knowledge  of  the  subject.  The  shreds,  casts,  or  membranous  masses, 
consist  of  "  a  transparent,  amorphous,  basement  substance,  here  and 
there  indistinctly  fibrillated,  and  having  imbedded  in  it  granules,  free 
nuclei,  and  small,  shriveled,  irregular,  and  rather  granular  cells." 
Chemically,  this  material  has  the  same  reactions  as  mucus  (Da  Costa) 
— a  fact  which  might  a  priori  be  expected,  since  this  false  membrane 
is  nothing  more  than  solidified  mucus,  the  granules,  free  nuclei,  and 
granular  cells  found  in  it  being  remains  of  mucus-cells  which  escaped 
entire  destruction  in  the  process  of  solidification.  The  mucous  mem- 
brane of  the  rectum,  in  a  case  examined  by  Da  Costa,  was  intensely 
injected. 

Symptoms. — The  attacks  are  announced  by  a  feeling  of  soreness 
and  distention  of  the  abdomen,  and  constipation.  There  is  no  fever, 
the  hands  and  feet  are  cold  and  moist,  and  the  general  condition  that 
of  depression,  in  which  the  mind  participates.  Before,  indeed,  any 
local  manifestations  of  disease,  there  are  apt  to  be  attacks  of  hysteria 
or  hypochondriasis,  and  the  subjects  of  this  disease  are  nervous,  excit- 
able, neuralgic.  The  pains  have  the  colicky  character,  are  felt  around 
the  umbilicus  chiefly,  and  are  exceedingly  severe  and  depressing. 
They  continue  for  a  half  hour,  for  an  hour  or  two,  and  even  longer, 
and,  after  a  variable  interval  of  some  hours'  duration,  occur  again. 
Thus,  during  the  twenty-four  hours,  there  may  be  six  or  more  par- 
oxysms. The  distress  does  not  cease  with  the  subsidence  of  the  acute 
pain  :  a  feeling  of  rawness  and  soreness  remains,  and  the  abdomen  is 
so  sensitive  to  pressure  that  peritonitis  may  be  suspected.  Very  con- 
siderable tenesmus  exists,  and  more  or  less  mucus,  with  or  without 
blood,  is  passed,  as  in  acute  catarrh  of  the  rectum.  There  may  be 
several  loose  evacuations  a  day,  or  the  bowels  may  be  confined. 
After  several  days  of  suffering,  there  will  be  discharged,  with  great 
pain  and  tenesmus,  shreds  of  membrane  or  cylindrical  casts  of  the 
bowel.  Great  relief  is  experienced.  The  soreness  subsides,  the  dis- 
tention lessens  at  once,  and  the  tenderness  diminishes.  The  patient  is 
left  in  a  condition  of  great  debility  and  much  emaciated,  for  during 
the  paroxysm  there  is  complete  anorexia,  and  sometimes  vomiting,  so 
that  but  little  food  is  taken.  The  paroxysms  are  rarely  single  ;  in  a 
week  or  two,  or  after  several  months,  there  is  a  renewal  of  the  same 
experiences.  In  one  of  the  author's  cases  there  were  paroxysms  sev- 
eral times  a  week  for  three  weeks,  the  patient  passing  an  almost  in- 

*  "The  American  Journal  of  the  Medical  Sciences,"  October,  1871,  p.  321,  et  seq. 


CROUPOUS   OR   MEMBRANOUS  ENTERITIS.  81 

credible  quantity  of  false  membrane.  The  same  woman,  in  an  attack 
three  years  before,  had  a  succession  of  paroxysms  for  six  weeks,  and 
was  so  reduced  that  her  life  was  despaired  of.  During  the  interval  of 
three  years  there  were  no  paroxysms,  but  she  suffered  from  constant 
troubles  of  digestion.  In  the  cases  related  by  Da  Costa,  disorders  of 
digestion  continued  and  were  very  persistent.  Acidity,  ulcers  of 
the  moiith,  red,  tender,  and  coated  tongue,  were  marked  features. 
Disorders  of  the  nervous  system,  also,  were  very  pronounced.  Hys- 
teria, hypochondriasis,  headache,  impaired  memory,  and  defects 
of  the  special  senses,  are  mentioned  by  Da  Costa  in  the  first  rank 
as  symptoms.  In  women,  too,  the  menstruation  was  deranged, 
and  various  diseases  of  the  sexual  system  were  present.  In  one 
of  the  author's  cases  membranous  dysmenorrhcea  had  existed  for 
some  years.  As  regards  the  intestinal  symptoms,  including  the  pas- 
sage of  pseudo-membrane,  variations  from  the  description  above 
given  have  been  noted.  The  pain  may  continue  during  the  interval 
between  the  paroxysms,  although  it  is  much  less  severe,  and  the 
membrane  may  be  present  in  all  the  discharges  occurring  during 
months  or  years. 

Course,  Duration,  and  Termination.  —  The  course  of  membranous 
enteritis  is  irregular,  and  the  duration  indefinite.  It  may  occur  in 
paroxysms  of  a  very  acute  character  in  quick  succession,  lasting  two 
or  three  weeks  or  more,  and  followed  by  an  interval  of  comparative 
health,  to  be  succeeded  after  months  or  years  by  the  same  succession 
of  symptoms.  Or  the  cases  may  be  less  acute,  and  continue  for 
months  or  even  years. 

Diagnosis, — The  distinction  is  to  be  made  between  membranous 
enteritis,  dysentery,  and  tape-worm.  The  passage  of  shreds  and  casts 
of  false  membrane  separates  this  malady  from  dysentery,  unless  there 
occurs  separation  or  desquamation  of  the  epithelium  in  the  latter, 
when  the  aid  of  the  microscope  must  be  invoked.  The  smallest  shreds 
of  false  membrane  may  be  confounded  with  the  strobila  of  a  tape- 
worm colony,  but,  as  the  latter  has  a  perfectly  well-defined  structure, 
and  has  the  power  of  independent  movement  for  a  short  time,  only 
ignorance  could  possibly  hesitate. 

Treatment. — The  suffering  which  attends  this  malady  requires  re- 
lief, and  the  preparations  of  opium  must  be  used.  The  most  effective 
anodyne  treatment  is  the  hypodermatic  injection  of  morphia.  Next 
to  this  are  enemata  of  starch  and  laudanum.  No  specific  treatment 
has  been  proposed,  and  only  symptoms  are  to  be  prescribed  for.  In 
the  author's  experience,  minute  doses  of  corrosive  sublimate,  of  cop- 
per sulphate,  and  of  arsenic  persistently  used,  are  the  most  effective 
remedies  for  the  more  chronic  cases  ;  for  the  acute,  an  emulsion  of 
almond-oil  and  turpentine,  or  of  castor-oil  and  turpentine  when  there 
is  constipation.  The  author  has  had  good  results  from  tincture  of 
6 


82  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

nux  vomica,  and  tincture  of  physostigma,  fifteen  to  twenty  drops  of 
each  ter  in  die,  for  the  subacute  and  chronic  cases. 


DYSENTERY. 

Definition. — In  common  language  dysentery  is  known  as  "  flux  "  ; 
sometimes  as  "  bloody  flux  "  ;  in  technical,  as  ulcerative  colitis.  It  is 
a  disease  characterized  by  tormina,  tenesmus,  mucus,  and  mucus-and- 
blood  stools,  burning  pain,  with  more  or  less  constitutional  disturbance. 
It  occurs  in  the  sporadic,  endemic,  or  epidemic  form,  and  in  the  latter 
seems  to  be  propagated  by  a  specific  virus. 

Causes. — It  occurs  in  both  sexes  and  at  all  ages.  Sudden  arrest  of 
perspiration  by  exposure  to  cold,  and  especially  to  cold  and  dampness 
combined,  is  one  of  the  most  common  causes.  Climatic  influences  are 
very  important  factors  in  its  production.  It  is  a  disease  of  those  parts 
of  the  year  in  which  the  change  of  temperature  from  night  to  day  is 
greatest,  as  in  the  later  summer  and  autumn,  and  in  warm  rather  than 
in  cold  climates.  It  is  especially  prevalent  in  malarious  regions,  doubt- 
less because  of  the  congestion  of  the  portal  circulation  induced  by 
paroxysms  of  ague.  Agents,  whether  of  food  or  medicine,  producing 
irritation  of  the  mucous  membrane,  may  cause  a  dysenteric  attack.  Is 
there  a  specific  virus  ?  Although  during  the  existence  of  an  epidemic 
the  mode  of  propagation  would  indicate  the  existence  of  a  specific  in- 
fective material,  yet  it  is  probable  that  this  is  nothing  more  than  the 
dysenteric  discharges  themselves  acquiring  increased  virulence  by  the 
aggregation  of  numbers  of  sick  under  unfavorable  hygienic  conditions. 
The  dysenteric  excreta  undergo  certain  fermentative  changes,  probably, 
by  which  their  infective  property  receives  additional  strength.  They 
are  admitted  to  the  ground-water,  in  the  dried  state  ;  finely  divided  they 
are  distributed  by  the  air,  and  in  many  ways,  by  the  atmosphere,  food, 
and  drink,  they  reach  the  intestinal  canal  of  man,  and  there  induce 
the  characteristic  disturbances  and  structural  alterations  of  dysentery. 
As  an  epidemic,  dysentery  is  a  prevalent  disease  in  armies,  in  jails,  in 
tenement-houses — wherever,  indeed,  numbers  of  human  beings  are 
crowded  together  under  unfavorable  hygienic  conditions.  Indeed,  it 
seems  almost  certain  that  ileo-colitis  and  ulcerative  colitis  may  be 
induced  by  the  emanations  from  fecal  accumulations,  and  by  the 
gaseous  products  of  animal  decomposition.  Unlike  contagious  and 
infective  diseases,  one  attack  of  dysentery  does  not  confer  immunity  ; 
in  fact,  the  tendency  is  increased  with  the  number  of  attacks. 

Pathological  Anatomy. — The  structural  alterations  of  dysentery 
may  be  comprehended  in  two  groups,  catarrhal  or  sero-purulent,  and 
croupous  or  fibrinous. 

The  first  step  in  the  series  of  changes  occurring  in  the  catarrhal 
form  is  an  intense  hyperemia,  the  mucous  membrane  being  of  a  deep 


DYSENTERY.  83 

reddish  color,  with  here  and  there  blackish  points.     The  redness  is  not 
universal,  but  at  the  summits  of  the  mucous  folds.     This  congestion  is 
not  limited  to  the  mucous,  but  extends  also  to  the  submucous  connec- 
tive tissue.     As  a  result  of  this  congestion  there  is  over-production  of 
mucus,  which  is  found  adherent,  but  not  closely,  to  the  membrane,  and 
the  follicles  enlarge  from  an  accumulation  of  their  contents,  while  just 
around  them  is  a  girdle  of  enlarged  vessels.     The  submucous  tissue 
thickens  greatly,  and  is  infiltrated  with  serum,  and  this  infiltration 
extends  to  the  muscular  layer.     Softening  of  the  mucous  membrane  now 
ensues,  and  undergoes  disintegration  and  gradual  detachment,  leaving 
still  adherent  here  and  there  portions  of  membrane  with  ragged  edges, 
and  a  coating  of  fibrinous  pellicle,  still  in  place.     The  follicles  resist 
the  destruction  from  softening  longer  than  other  portions  of  the  mem 
brane,  but  finally  they  slough  out.     The  disintegration  of  the  mucous 
membrane  is  the  result  of  an  enormous  multiplication  of  pus-cells  within 
the  interstices  ;  the  pressure  is  increased  by  the  swollen  vessels,  and 
rapid  necrosis  (softening)  ensues.     Recovery  readily  takes  place  in  the 
cases  of  catarrhal  inflammation  before  the  softening  begins,  and  after 
softening  if  the  destruction  is  not  extensive.     Repair  is  effected  by 
cicatrices,  which  are  much  smoother,  and,  of  course,  devoid  of  the 
gland-structures,  and  are  therefore  easily  recognized.     In  the  fibrinous 
or  diphtheritic  dysentery  the  alterations  of  structure  are  very  differ- 
ent.    The  initial  •  change,  as  in  the  catarrhal  form,  is  an  extensive 
hyperasmia,  but,  instead  of  being  confined  to  the  summits  of  the  folds, 
(valvulae  conniventes  of  the  small  intestines,  and  the  folds  from  con- 
traction of  the  muscular  layer  in  the  large)  there  is  a  universal  deep, 
bluish-red  congestion  of  the  lower  end  of  the  ilium,  and  the  whole  of 
the  colon.     Extensive  extravasations  of  blood  infiltrate  the  whole  tis- 
sue of  the  mucous  membrane,  but  it  is  especially  invaded  and  trans- 
formed by  a  fibrinous  exudation.     The  proper  structure  of  the  mucous 
membrane  disappears  entirely,  except  remains  of  the  tubular  glands, 
and  it  presents  internally  a  reddish-white  surface,  variegated  with  ir- 
regular blackish  and  reddish  figures.     The  result  of  these  changes  is 
to  convert  the  membrane  into  a  dense,  parchment-like,  and  rather  un- 
yielding tissue,  composed  largely  of  the  deposited  fibrin.     If  death  do 
not  take  place  when  the  alterations  of  the  mucous  membrane  have 
reached  this  point,  gangrene  ensues.     Although  the  ultimate  changes 
in  the  two  forms  of  dysentery  are  so  distinct,  yet  in  most  cases  the 
alterations  found  post  mortem  are  made  up  of  both  forms,  the  catarrhal 
and  fibrinous.     Those  parts  of  the  intestinal  wall  affected  by  the  fibri- 
nous inflammation  are  thicker  and  more  prominent  than  those  attacked 
by  the  catarrhal.     Hence  the   surface  is  uneven,  the  fibrinous  parts 
dark  from  the  presence  of  extravasated  blood,  or  reddish- white  where 
the  fibrin  predominates.     Local  gangrene  patches  appear,  in  size  from 
a  copper  cent  to  a  silver  dollar  ;  the  membrane  disintegrates  and  is  de- 


84  DISEASES   OF  THE   DIGESTIVE   SYSTEM, 

tached  in  considerable  sloughs,  leaving  a  deep  excavation,  which  extends 
deeper  by  succeeding  necrosis  to  the  peritoneum.  The  purulent  infil- 
tration in  those  parts,  the  seat  of  catarrhal  inflammation,  also  leads  to 
extensive  destruction  of  the  submucous  layer  and  large  excavations 
beneath  the  mucous  membrane,  which  is  either  detached  as  a  whole, 
or  in  turn  yields  to  necrosis.  These  more  superficial  catarrhal  exca- 
vations contrast  strongly  with  the  dark-red  or  blackish  sloughs  of  the 
fibrinous. 

The  extent  to  which  the  intestine  is  involved  varies  greatly.  The 
rectum,  the  caecum,  or  the  sigmoid  flexure,  may  be  alone  involved  ; 
the  whole  of  the  large  intestine,  the  disease  beginning  below  and  ex- 
tending upward,  may  be  invaded.  Repair  is  possible  only  when  a 
small  extent  of  the  mucous  membrane  has  been  destroyed  by  gangrene. 
When  the  morbid  process  is  arrested,  the  sloughs  separate,  granula- 
tions spring  up,  and  the  excavations  are  closed  by  cicatrices,  which  by 
subsequent  contraction  may  seriously  encroach  on  the  lumen  of  the 
bowel.  The  structural  alterations  are  not  limited  to  the  mucous,  sub- 
mucous and  muscular  layers.  When  the  ulcers  reach  the  peritoneum, 
this  membrane  becomes  cloudy,  then  intensely  injected,  and  fibrinous 
exudation  forms  and  adhesions  are  contracted  to  neighboring  surfaces. 
When  perforation  ensues,  a  limiting  inflammation  may  cut  off  the  in; 
jured  parts  from  the  general  cavity,  and  form  a  purulent  collection, 
or  general  peritonitis  may  ensue  if  the  shock  does  not  terminate  the 
history  of  the  case. 

The  mesenteric  glands  are  enlarged,  hypersemic,  and  softened,  and 
often  are  broken  down  into  abscesses.  The  liver  is  very  commonly  the 
seat  of  numerous  small  abscesses,  from  embolic  obstruction  of  the 
radicles  of  the  portal  vein.  The  lungs  present  in  their  dependent 
parts  the  changes  of  hypostasis.  The  heart  is  small,  flabby,  and  its 
muscular  tissue  more  or  less  fatty. 

Symptoiris. — In  the  epidemic  form  dysentery  may  begin  suddenly, 
without  any  preliminary  symptoms,  and  with  great  violence,  but  in 
the  endemic  and  sporadic  form,  and  in  the  milder  cases  during  epi- 
demics, there  is  usually  a  prodromic  or  preliminary  stage.  There  is 
more  or  less  catarrh  of  the  intestines,  diarrhoea,  chilliness  followed  by 
feverishness,  toward  evening  especially,  and  that  state  of  general  dis- 
comfort known  as  inalaise  general. 

In  the  mildest  cases  of  dysentery  there  is  no  fever,  but  when  the 
symptoms  are  at  all  pronounced  there  is  fever  of  a  remittent  type, 
the  exacerbation  occurring  toward  evening.  The  type  of  the  fever  is, 
of  course,  determined  by  the  extent  of  the  local  lesions. 

When  actual  dysentei'ic  symptoms  come  on,  which  happens  in  two 
or  three  days  after  the  first  of  the  prodromic  period,  very  decided  ab- 
dominal pain  is  felt  along  the  course  of  the  descending  colon  and  about 
the  sigmoid  flexure,  and  is  increased  by  pressure  at  these  points.    These 


DYSENTERY,  85 

abdominal   pains,  felt  also    somewhat  about  the  umbilicus,   are    de- 
scribed by  the  term  tormina — "  colicky  pains."     There  is  pain  of  a 
burning  character  in  the  rectum,  but  especially  a  sense  of  the  presence 
of  a  foreign  body,  with  the  desire  to  strain  for  its  expulsion.     The 
patient  resorts  again  and  again  to  the  close-stools,  and  makes  strong 
efforts  at  expulsion,  but  instead  of  any  fseces  being  discharged  he  only 
brings  away  some  jelly-like  matter — mucus — either  alone  or  tinged 
with  blood,  and  occasionally  a  hard  ball  of  faeces  {scybala),  but  without 
any  relief.     The  feeling  of  bearing  down  {tenesmus)  and  the  burning 
pain  felt  in  the  rectum  and  through  the  hips  continue  as  before,  so  that 
he  finds  it  impossible  to  quit  the  stool,  or  returns  every  few  minutes, 
and  each  time  he  sinks  back  to  bed  exhausted  and  unrelieved.     At  the 
beginning,  before  the  characteristic  dysenteric  stools  appear,  there  are 
loose  fecal  evacuations  containing  mucus,  voided  with  great  pain.    Pres- 
ently, however,  faeces  are  no  longer  present  in  the  evacuations  ;  they 
consist  of  a  grayish,  tough,  transparent  mucus  in  pellets  or  small  masses, 
containing  here  and  there  whitish  granules,  which  have  been  likened  to 
grains  of  sago.     On  the  second  or  third  day,  blood  appears  in  the  stools, 
and  the  debris  of  epithelium  are  mixed  with  the  mucus.    In  the  mildest 
cases,  the  course  of  the  disease  is  ended  with  these  manifestations. 
These  do  not  differ  from  the  mildest  cases  seen  during  the  existence  of 
an  epidemic  ;  on  the  other  hand,  the  most  formidable,  the  fulminant 
cases,  may  occur  sporadically.     In  the  more  pronounced  cases,  after 
three  or  four   days,   severer  symptoms  make  their  appearance — the 
amount  of  blood  discharged  increases  ;  not  only  the  debris  of  epithe- 
lium, but  the  pellicular  neo-membrane  (an  exudation)  and  necrosed 
parts  of  the  mucous  membrane  are  now  to  be  detected  in  the  stools. 
The  stools  have  no  longer  any  fecal  odor,  but  are  very  fetid  from  the 
presence  of  gangrenous  portions  of  mucous  membrane.     The  grayish, 
transparent  mucus  gives  place  to  a  puriform  fluid,  and  there  is  not 
only  considerable  admixture  of  blood,  but  a  good  many  clots  of  pure 
blood  are  also  discharged,  and  indeed  a  real  haemorrhage  may  occur, 
A  stool  may  consist  of  a  bloody,  purulent  fluid  and  scybala,  and  the 
next  be  composed  largely  of  an  extremely  fetid,  brownish  fluid  con- 
taining bits  of  neo-membrane  and  masses,  often  of  considerable  size, 
of  decomposing  gangrenous  sloughs  of  the  mucous  membrane.     Some- 
times a  cast  of  a  part  of  the  bowel,  consisting  of  the  mucous  membrane 
in  a  complete  cylinder,  all  of  its  parts  distinct  enough  for  recognition, 
will  be  discharged.     These  ought  not  to  be  confounded  with  the  infi- 
nitely rarer  accident  of  a  slough  of  the  bowel  itself,  several  feet  in 
length,  cast  off  by  intussusception.     As  has  already  been  pointed  out, 
in  the  catarrhal  form  of  dysentery,  deep-seated  suppuration  in  the 
submucous  layer  sometimes  extends  widely,  and  the  mucous  membrane 
sloughs  off  before  it  has  had  time  to  become  gangrenous.     During  the 
tormina  nausea  is  often  felt,  and  vomiting  occasionally  occurs.     In  the 


86  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

severe  cases,  vomiting  is  constantly  present  and  adds  materially  to  the 
gravity.  The  vomited  matters  consist  of  articles  of  food  and  drink,  of 
gastric  mucus,  and  ultimately  of  biliary  matters  from  the  gall-bladder. 
The  bladder  in  severe  cases  is  also  affected  by  tenesmus.  The  urine  is 
scanty,  high-colored,  and  very  acid,  and  therefore  irritating,  and  so 
sensitive  does  the  bladder  become  that  a  few  drops  of  urine  present  in 
it  excite  the  tenesmus,  and  in  the  straining  both  the  bladder  and  the 
rectum  are  simultaneously  affected.  The  frequency  of  the  stools  repre- 
sents pretty  nearly  the  gravity  of  the  case.  In  the  mild  cases  there  may 
be  ten  to  twenty  daily  ;  in  the  severe  cases  forty  or  fifty,  and  in  the 
fulminant  they  may  reach  a  hundred  or  more.  Lessened  frequency 
is  a  good  indication  when  the  character  is  improved.  The  amount 
discharged  is  small  unless  haemorrhage  occurs.  Artificial  distinctions 
based  on  the  character  of  the  stools  have  been  made,  but  these  have 
no  practical  importance.  It  must  be  obvious  that  a  disease  affecting 
so  large  a  part  of  the  intestinal  mucous  membrane,  and  of  so  formidable 
a  character  in  itself,  must  quickly  impair  the  bodily  forces.  Even  in 
the  mild  cases  considerable  emaciation  occurs  and  the  return  to  health 
is  slow.  In  the  severe  cases,  systemic  infection  results  from  the  prod- 
ucts of  decomposition  and  from  the  gangrene,  and  they  wear  the 
aspect  peculiar  to  this  state.  The  weakness  early  reaches  the  point 
that  the  patient  is  unable  to  leave  the  bed  ;  the  evacuations  pass  with- 
out his  control ;  the  anus  and  neighboring  parts  become  excoriated 
and  bed-sores  quickly  form.  The  face  wears  an  anxious  expression  and 
is  pinched  ;  the  skin  is  dry,  harsh,  and  wrinkled  ;  the  pulse  small,  quick, 
and  feeble.  With  the  most  painstaking  care  the  person  and  bedding 
of  the  patient  will  be  fouled  with  the  discharges  and  emit  a  horribly 
fetid  odor.  From  this  condition  of  depression  the  case  passes  into  the 
stage  of  collapse,  when  the  pulse  ceases  at  the  wrist  and  the  heart  beats 
very  feebly,  an  obstinate  hiccough  comes  on,  the  skin  is  covered  with 
a  cold  sweat,  the  hands  and  feet  become  cold  and  livid  ;  the  face  is 
shrunken,  the  eyes  deej)ly  sunk,  the  voice  husky.  In  this  condition 
the  patient  usually  betrays  a  singular  apathy,  although  the  mind  re- 
mains clear  until  the  failure  of  oxygenation  of  the  blood  causes  carbonic - 
acid  poisoning  and  stupor.  The  state  of  collapse  may  not  come  on  in 
this  gradual  way,  but  the  patient  pass  suddenly  into  it,  by  reason  of  per- 
foration of  the  bowel  and  the  resulting  shock  followed  by  peritonitis. 
Death  does  not  necessarily  ensue  immediately  after  the  symptoms  of 
collapse  have  been  fully  developed.  The  patient  may  remain  in  this 
low  state  for  several  days,  now  presenting  delusive  appearances  of 
improvement,  now  declining.  Various  complications  may  arise  during 
the  course  of  dysentery.  Thrombosis  of  the  intestinal  veins,  or  a  form 
of  phlebitis,  or  the  absorption  and  deposition  in  the  liver  of  some  un- 
known morbific  material,  may  excite  inflammation  and  abscess  of  the 
liver.     This  is  a  common  accident  in  tropical  regions  and  in  the  interior 


DYSENTERY.  g7 

of  the  American  Continent.  Hepatic  abscess  is,  however,  more  fre- 
quently clue  to  the  milder  than  the  sevei-er  forms  of  dysentery,  because 
of  the  destruction  by  gangrene  and  the  rupture  of  vascular  communi- 
cation, which  takes  place  in  the  latter.  It  follows  disease  of  the  rectum 
much  more  commonly  than  of  the  colon  or  caecum,  because  of  the 
greater  abundance  of  large  vessels  in  the  latter  and  the  comparative 
sluggishness  of  the  blood-current.  Besides  abscess  of  the  liver,  puru- 
lent collections  are  sometimes  found,  as  the  author  has  seen,  in  the 
lymphatics  at  the  root  of  the  lungs  and  elsewhere.  Peritonitis  is 
a  usual  complication,  not  due  necessarily  to  perforation,  but  the  ex- 
tension of  the  ulceration  to  the  peritoneum.  Increased  tenderness 
of  the  abdomen  and  an  exacerbation  of  the  systemic  symptoms  are 
results. 

Course,  Duration,  and  Termination. — In  the  mild  cases  the  disease 
usually  begins  with  diarrhoea  ;  tormina  and  tenesmus  are  felt  about 
the  second  day,  when  also  mucus  appears  mixed  with  faeces.  About 
the  third  day  the  more  characteristic  stools  are  seen,  and  the  disease 
has  attained  its  height  on  the  fifth  and  sixth  day  when  improvement 
begins,  and  convalescence  is  established  about  the  eighth  day.  The 
signs  of  improvement  are  a  diminution  in  the  number  and  frequency 
of  the  stools  ;  the  reappearance  of  faeces,  and  the  disappearance  first  of 
the  blood  and  next  of  the  mucus.  In  the  more  severe  cases  the  dura- 
tion is  more  protracted.  The  maximum  in  the  intensity  of  the  symp- 
toms continues  for  several  days  ;  the  state  of  adynamia  is  more  serious 
and  prolonged,  and  the  return  toward  health  may  be  by  almost  insen- 
sible gradations,  lasting  several  days.  The  prodromic  period  in  such 
cases  will  be  about  three  days,  the  fully  developed  period  will  range 
from  four  days  to  a  week,  and  the  period  of  gradual  improvement  will 
last  about  the  same  time,  so  that  the  whole  duration  of  such  a  case  will 
be  about  three  weeks,  while  the  convalescence  will  require  a  month 
for  full  restoration  to  health.  The  termination  may  be  in  partial 
recovery,  or  in  chronic  dysentery.  When  this  is  the  case,  the  more 
severe  symptoms  subside,  the  stools  improve  in  character,  but  they 
never  become  entirely  healthy,  and  the  general  condition  is  more 
favorable.  Xow  fecal  stools,  with  only  a  little  mucus  and  blood,  are 
passed,  but  these  may  be  succeeded  by  evacuations  entirely  of  pus  and 
blood.  With  this  varying  fortune  the  case  may  proceed  for  months, 
even  years,  the  patient  in  a  feeble  state,  emaciated,  and  yet  able  to 
keep  out  of  bed,  or  so  reduced  as  to  be  unable  to  sit  up  except  for  a 
little  while  every  day.  The  prolonged  suppuration  in  these  cases  in- 
duces amyloid  degeneration  of  the  liver,  spleen,  and  kidneys,  the  ulti- 
mate result  being  anasarca  and  albuminuria. 

Another  mode  of  partial  recovery  is  narrowing,  contraction,  and 
deformation  of  the  bowels,  the  effect  of  which  is  to  impair  assimilation 
and  nutrition,  so  that  after  a  period  of  improvement  a  progressive  loss 


88  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

of  flesh  and  strength  is  observed,  and  ultimately  death  occurs  by  ex- 
haustion. 

Prognosis. — Opinions  must  be  expressed  with  caution  in  the  early 
stages  of  dysentery,  for  it  is  not  then  possible  to  estimate  correctly  the 
extent  of  the  inflammation,  nor  its  form.  A  favorable  prognosis  can 
be  given  in  those  cases  which  continue  mild,  and  even  in  severe  cases, 
if  the  signs  of  collapse  are  absent.  Whenever  the  symptoms  begin 
with  great  violence  (fulminant  form)  a  guarded  prognosis  is  judieious. 
If  the  symptoms  of  collapse  are  persistent,  especially  if  gangrenous 
sloughs  appear  in  the  stools,  an  unfavorable  opinion  must  be  given. 
In  severe  and  protracted  cases  that  are  apparently  improving,  the 
probability  of  a  partial  recovery  should  not  be  lost  sight  of. 

Diagnosis. — The  symptoms  are  so  characteristic  that  a  differentia- 
tion is  rarely  required,  except  as  between  simple  and  acute  catarrh  of  the 
rectum  (proctitis)  and  dysentery  proper.  The  dysenteric  sym.ptoms  in 
proctitis  are  much  less  severe  ;  the  discharges  consist  of  mucus  and 
muco-pus,  sometimes  intermixed  with  blood,  but  never  the  foul  dis- 
charges of  dysentery,  the  shreds  of  false  membrane,  the  gangrenous 
sloughs,  etc.,  which  constitute  so  characteristic  an  evacuation.  In 
croupous  enteritis,  which  is  as  rare  as  dysentery  is  common,  there  are 
discharges  of  shreds  of  pseudo-membrane  with  tormina  and  tenesmus, 
but  the  attacks  are  paroxysmal,  the  evacuations  continue  the  same,  and 
the  subsequent  history  is  widely  different  from  that  of  dysentery. 

Treatment. — As  in  this  disease  the  nutrition  of  the  body  suffers 
severely,  the  right  use  of  aliment  is  important  from  the  beginning. 
If  the  stomach  is  irritable,  milk,  with  one  fourth  lime-water,  is  the  best 
food.  If  there  is  but  little  nausea,  and  especially  if  the  digestion  re- 
mains good,  the  patient  can  take  milk,  eggs,  beef-juice,  ice-cream, 
boiled  custard,  oyster-soups,  mutton,  chicken,  and  beef  broth,  and  simi- 
lar articles,  but  solids  and  aliments  generally  leaving  much  residuum, 
and  especially  coarse  articles,  are  highly  objectionable,  because  they 
increase  by  friction  the  irritation  of  the  inflamed  membrane.  Where 
there  is  much  depression  of  the  powers  of  life,  egg-nogg  (milk,  egg, 
and  brandy)  may  be  freely  given,  and  champagne  be  used  to  allay 
vomiting. 

Of  medicinal  measures,  the  treatment  by  saline  laxatives  is  of  the 
highest  importance.  Bretonneau,  preceptor,  and  Trousseau,  pupil, 
strongly  urged  the  sulphates,  and  the  author  is  convinced  that  the  sul- 
phate of  magnesia  in  solution  with  dilute  sulphuric  acid  is  entitled  to 
the  first  place  as  a  remedy.  It  must  be  given  in  laxative  doses,  and  at 
the  right  time — that  is,  before  the  mucous  membrane  has  begun  the 
process  of  disintegration.  It  serves  a  triple  purpose  :  it  empties  the 
canal  of  retained  faeces;  it  lessens  hypersemia  by  setting  up  an  outward 
osmotic  flow  ;  its  after-effect  is  astringent  and  sedative.  Next  to  the 
sulphate  of  magnesia,  and  by  many  given  the  first  place,  is  ipecac. 


DYSENTERY.  89 

The  experience  with  this  remedy,  ancient  and  modern,  is  now  so  great 
that  the  limit  of  its  curative  power  is  well  and  accurately  defined.  It 
is  applicable  to  the  first  stage  of  dysentery,  before  the  mucous  mem- 
brane is  stripped  off.  It  must  be  given,  according  to  recent  Indian 
experiences,  in  which  the  author  in  the  main  concurs,  in  scruple  to 
drachm  doses,  every  four  to  six  hours.  The  effects  to  be  derived  from 
it  are  these  :  The  first  doses  empty  the  stomach  thoroughly,  then  a 
tolerance  is  established,  and  the  considerable  doses  prescribed  are  car- 
ried quietly  by  the  stomach,  but  act  on  the  intestinal  canal,  produc- 
ing copious  bilious  evacuations,  so  characteristic  as  to  be  called  "  ipe- 
cac-stools "  ;  after  the  purgative  action  ceases  a  calmative  and  astrin- 
gent action  continues.  The  utility  of  ipecacuanha  ceases  with  the 
production  of  the  characteristic  stools,  and  very  decided  amelioration 
in  the  remediable  cases  usually  follows.  There  is  one  form  of  dysen- 
tery, above  all  others,  in  which  the  ipecac-treatment  is  signallv  bene- 
ficial— the  puerperal.  The  author  has  witnessed  some  remarkable 
cures  in  cases  of  puerperal  dysentery,  a  disease  which  is  well  known 
to  be  very  dangerous  to  life.  As  regards  the  dose,  the  large  quantity 
of  a  di'achm  prescribed  by  our  Indian  colleagues  seems  unnecessary  in 
our  temperate  climate.  It  will  be  rarely  necessary  to  give  more  than 
twenty  grains  at  a  dose.  It  is  best  administered  in  milk.  The  next 
remedy  in  point  of  efficiency  for  the  treatment  of  the  first  stage  of 
dysentery  is  castor-oil,  administered  in  purgative  doses,  for  the  purpose 
of  ridding  the  canal  of  acrid  and  fermenting  materials,  and  of  retained 
fjEces,  and  to  secure  the  after-quietude  which  succeeds  to  the  action  of 
a  purgative.  After  using  one  of  the  agents  of  the  cathartic  group  as 
above  directed,  what  remedies  are  most  appropriate  for  the  treatment 
of  that  condition  in  which  either  purulent  or  fibrinous  infiltration,  or 
both,  is  taking  place  ?  Under  these  circumstances  an  emulsion  of  oil 
(almond-oil)  and  turpentine  is  very  serviceable,  and  combined  with 
opium,  if  the  pain  be  very  severe.  When  destruction  of  the  mucous 
membrane  is  beginning,  the  most  effective  remedies  are  corrosive  sub- 
limate, sulphate  of  copper,  sulphate  and  oxide  of  zinc,  acetate  of  lead, 
bismuth,  arsenic,  etc.  Of  this  formidable  list,  sulphate  of  copper  and 
arsenic  are  most  effective.  They  ought  to  be  combined  with  opium. 
The  author  has  had  excellent  results  from  the  use  of  Fowler's  solution, 
one  drop,  and  deodorized  tincture  of  opium,  five  to  twenty  drops  every 
three  hours.  Sulphate  of  copper  must  be  given  in  small  doses  (one 
twentieth  of  a  grain)  every  three  hours,  with  morphia  (one  eighth  to 
one  twelfth  of  a  grain).  Bismuth  in  large  dose  (3j  —  3ij)  every 
four  hours  is  sometimes  beneficial,  especially  if  administered  with  car- 
bolic acid.  Numerous  vegetable  astringents,  OT^dng  their  therapeuti- 
cal power  to  the  tannic  acid  which  they  contain,  have  been  much  em- 
ployed, with  more  or  less  advantage,  but  they  are  not  equal  to  the 
mineral  astringents.     Applications  to  the  rectum  and  colon  are  un- 


90  DISEASES   OF  THE  DIGESTIVE   SYSTEM. 

questionably  useful.  By  the  method  of  irrigation  the  whole  of  the 
colon  may  be  safely  reached.  Excellent  results  are  obtained  by  wash- 
ing out  the  bowels  with  warm  water  (100°  to  IDS'"  Fahr.).  The  patient 
is  placed  on  his  right  side,  the  thighs  Avell  flexed  on  the  pelvis,  the  hips 
elevated  and  brought  to  the  margin  of  the  bed,  the  chest  and  head  on 
a  lower  level.  The  anal  tube  is  inserted  two  or  three  inches,  and  the 
reservoir  is  placed  at  a  suflicient  height  to  insure  the  passage  of  the 
water.  Various  demulcent  applications  may  also  be  made  in  this  way. 
Very  great  relief  is  afforded  by  the  injections  of  starch  and  laudanum 
after  an  evacuation,  or  especially  after  irrigation  and  washing  out  the 
bowels.  Much  emphasis  should  be  put  on  the  employment  of  nitrate 
of  silver  enemata.  They  possess  a  high  degree  of  utility  if  efficiently 
performed.  A  tube  which  is  not  acted  on  by  the  silver  salt  should  be 
passed  carefully  uj)  to  the  sigmoid  flexure,  and  about  eight  ounces  of 
a  strong  solution  of  silver  nitrate  (3j  —  3j  to  the  ounce)  should  be 
thrown  up.  The  time  for  performing  this  is  after  sufficient  quiet  has 
been  obtained  by  the  hypodermatic  injection  of  morphia.  So  rapidly 
is  the  insoluble  chloride  of  silver  formed  that  no  ill  results  can  follow 
the  strongest  solution  employed  for  this  purj)ose  ;  but,  if  there  be  any 
reason  to  apprehend  mischief,  a  solution  of  common  salt  may  be  inject- 
ed immediately  after  the  silver. 

If  the  injections  are,  for  any  reason,  inadmissible,  suj)230sitories  of 
cacao-butter  containing  morphia,  morjDhia  and  tannin,  morphia  or 
opium,  and  acetate  of  lead,  etc,  can  be  used  instead.  Lately  injections 
and  suppositories  of  fluid  extract  of  ergot,  and  of  ergotin,  have  been 
used,  and  apparently  with  good  results,  Ergotin  has  been  given  in- 
ternally, and,  in  some  epidemics,  with  an  apparent  utility,  which  the 
physiological  effects  will  hardly  warrant.  It  is  difficult  to  understand 
how  it  can  accomplish  anything  when  in  the  catarrhal  inflammation 
the  mucous  membrane  is  infiltrated  with  pus,  and  in  the  croupous  with 
fibrin.  After  the  use  of  the  saline  laxative,  or  the  ipecac,  the  morbid 
process  continuing,  is  there  no  means  of  securing  that  quietude  of  the 
intestine  which  will  permit  the  mineral  astringent  to  act  on  the  diseased 
surface?  The  author  believes  that  we  possess  such  an  agent  in  the 
hypodermatic  injection  of  morphia.  He  therefore  urges,  from  the 
point  of  view  of  personal  exi^erience,  this  means  of  treatment.  Besides 
giving  the  remedies  an  opportunity  to  act  on  the  diseased  surface,  the 
morphia  injections  suspend  that  violent  reflex  peristalsis  which  does 
so  much  injury  to  the  diseased  mucous  membrane.  External  ajaplica- 
tions,  if  not  curative,  are  grateful.  The  cold  wet  pack,  the  ice-bag,  and 
other  cold  applications,  are  sometimes  preferred  ;  but  generally  warm 
— rather  hot — applications  afford  more  relief.  The  turpentine  stupe 
is  generally  more  useful  than  other  warm  applications.  With  the  be- 
ginning of  the  symptoms  of  collapse,  active  stimulation  may  be  neces- 
sary.    The  best  form  of  stimulant  is  cognac  brandy,  as  it  is  at  the 


ULCERS   OF   THE   INTESTINES.  91 

same  time  astringent.  Beef -juice  and  brandy,  milk  and  brandy,  and 
egg-nogg,  are  combinations  of  food  and  stimulant  most  generally  use- 
ful. As  already  indicated,  the  strength  must  be  supported  from  the 
outset  by  suitable  nutriment.  It  is  necessary  to  keep  the  person  of  the 
patient  and  the  bedclothing  clean.  The  discharges  should  be  removed 
from  the  apartment  as  soon  as  passed,  and  should  be  thoroughly  disin- 
fected before  going  into  the  common  receptacle.  A  strong  solution  of 
sulphate  of  iron  is  a  cheap  and  effective  agent  for  this  purpose.  Some 
tincture  of  iodine  exposed  in  a  saucer  is  an  excellent  deodorizer  for 
the  apartment  of  the  patient. 

ULCERS    OF    THE   INTESTINES. 

Forms. — Ulcers  of  the  intestinal  canal  exist  in  thi-ee  forms  : 

Ulcers  from  mechanical  irritation. 

Ulcers  from  thrombosis  or  embolism. 

Ulcers  from  tuberculous  deposit. 

There  are  duodenal  ulcers,  csecal  ulcers,  and  rectal  ulcers,  and  an 
anatomical  classification  might,  therefore,  be  adopted.  It  will  be  con- 
venient, in  the  description,  to  study  these  ulcers,  according  to  their 
anatomical  position,  going  from  above  downward. 

The  Nature,  Symptoms,  and  Treatment  of  Ulcers  of  the  Duodenum. 
— The  first  or  transverse  part  of  the  duodenum  is  the  almost  exclusive 
seat  of  the  ulcer.  The  pathological  history  of  this  ulcer  is  the  same  as 
the  corresponding  ulcer  of  the  stomach.  The  great  factor  in  its  causa- 
tion is  thrombosis,  or  embolic  obstruction  of  a  vessel.  An  admirable 
instance  of  this  accident  (the  embolus  in  position,  the  ulcer  forming) 
has  been  reported,*  confirming  clinically  that  which  had  previously 
been  demonstrated  by  pathological  experimentation.  When  the  blood- 
supply  has  been  cut  off  from  a  part  of  the  mucous  membrane,  the 
digestive  juice,  no  longer  opposed  by  the  alkaline  stratum  beneath,  dis- 
solves or  digests  the  membrane,  and  an  ulcer  is  formed.  At  first  it  is 
a  round,  smooth,  sharply  defined  ulcer,  but  the  inflammation  which  is 
lighted  up  cuts  off  the  action  of  the  gastric  juice  from  the  adjacent 
healthy  tissues,  by  a  deposit  of  new  material  of  a  granulation-tissue 
structure,  and  especially  protects  the  bottom  of  the  excavation  ;  other- 
wise perforation  would  quickly  ensue  in  most  cases.  As  the  layers  of 
the  duodenum  are  invaded,  not  all  at  once,  but  successively,  and  as  the 
distribution  of  the  vessels  is  fan-shaped,  it  is  obvious  that  the  resulting 
ulcer  must  have  shelving  margins  and  a  stratified  appearance.  The 
term  "  crater -like  "  aptly  enough  describes  its  characteristics. 

This  description  of  the  process  by  which  duodenal  ulcers  are  formed 
can  be  applicable  to  ulcers  situated  in  the  first  part  of  the  duodenum 

*  Merkel,  "Wiener  Presse,"  various  numbers  in  1866. 


92  DISEASES   OF  THE   DIGESTIVE   SYSTEM. 

only,  for,  soon  after  the  acid  contents  of  the  stomach  reach  the  vertical 
part,  they  hegin  to  have  an  alkaline  reaction.  It  is  in  the  lirst  part 
that  the  ulcers  are  found,  and  they  are  sometimes  partly  in  the  stomach 
and  partly  in  the  duodenum.  They  are  usually  single,  and  occasionally 
multiple.  The  cause  that  gives  origin  to  one  may  produce  several  (em- 
boli), so  that  it  is  not  uncommon  to  find  gastric  and  duodenal  ulcers 
existing  at  the  same  time.  As  regards  the  relative  frequency  in  the  oc- 
currence of  ulcers  in  the  stomach  and  duodenum,  respectively,  they  are 
found  in  the  former  organ  thirty  times  more  frequently  than  in  the 
latter.  The  duodenal  ulcer  is  found  between  thirty  and  forty  years  of 
age  in  a  great  majority  of  cases,  and  becomes  very  rare  after  sixty 
(Krauss).*  As  to  sex,  the  preponderance  is  in  favor  of  males,  and  is  so 
extraordinary  in  proportion  as  fifty-eight  to  six.  Accident  in  the  collec- 
tion of  cases  had  something  to  do  with  these  figures.  Besides  the  causes 
already  mentioned,  burns  of  the  skin,  especially  of  the  chest  and  abdo- 
men, have  induced  ulceration  of  the  duodenum.  The  burns  must  be  of 
considerable  extent  to  bring  it  about,  sufficient  to  cause  a  reflex  spasm 
of  the  vessels,  thus  permitting  the  gastric  juice  to  act  on  the  membrane. 
If  the  ulceration  reaches  the  peritoneum  adhesions  may  be  contracted 
to  neighboring  organs,  to  the  stomach,  pancreas,  gall-bladder,  etc.,  and 
fistulous  communications  may  be  established  ultimately  between  them. 
In  the  process  of  widening  of  the  ulcer,  a  vessel  may  be  opened  and 
haemorrhage  result,  a  very  common  symptom,  occurring  in  one  half  of  the 
cases.  By  perforation  a  local  peritonitis  may  be  set  up,  adhesions  con- 
tracted, and  a  cavity  containing  sero-purulent  fluid,  shreds  of  tissue,  etc., 
formed  ;  or  the  general  cavity  of  the  peritoneum  may  be  entered  and 
general  peritonitis  excited.  When  an  ulcer  of  the  duodenum  heals, 
the  puckered  cicatrix  which  results  may  induce  remarkable  changes. 
Contraction  of  the  pyloric  orifice  and  dilatation  of  the  stomach  will  be 
results  of  the  cicatrization  of  an  ulcer  situated  at  the  entrance  to  the 
duodenum  ;  if  lower  down,  the  lumen  of  the  bowel  will  be  encroached 
on,  and  dilatation  occur  above  the  contraction.  An  ulcer  may  be  so 
situated  that  the  pancreatic  and  common  duct  of  the  liver  will  be  ob- 
structed with  the  usual  results  of  such  obstruction.  Ulcers  of  the  duo- 
denum situated  near  the  pyloric  orifice  will  be  accompanied  by  some  of 
the  symptoms  of  a  gastric  ulcer  situated  at  or  near  the  pylorus.  Vom- 
iting is  a  pretty  nearly  constant  symptom,  coming  on  several  hours  after 
eating.  Tenderness  to  pressure,  and,  when  the  ulceration  approaches 
the  peritoneal  surface,  rather  exquisite  tenderness,  is  felt  in  the  posi- 
tion of  the  duodenum.  Attacks  of  gastralgia,  of  enteralgia  rather,  and 
of  a  severe  character,  occur  under  the  same  circumstances  as  gastralgia 
in  stomach -ulcer.  The  pain  is  distributed  through  the  solar  plexus 
and  the  hepatic  plexus  also,  and  is  of  a  very  depressing  kind,  the 

*  "Das  perforirende  Geschwiir  im  Duodenum,"  Berlin,  1865,  p.  24. 


ULCERS   OF  THE   INTESTINES.  93 

action  of  the  heart  becoming  exceedingly  feeble,  the  surface  cold,  etc. 
Jaundice  may  also  be  present.  When  this  is  the  case,  it  would  be  im- 
possible to  differentiate  between  ulcer  of  the  duodenum  and  hepatic 
colic.  Hajniorrhage  may  take  place  by  emesis  or  by  stool.  In  duode- 
nal ulcer  it  may,  in  consequence  of  the  size  of  the  vessel  (the  ascending 
vena  cava,  for  example),  be  so  large  as  to  cause  death  immediately. 
The  blood,  unless  in  large  amount,  is  much  changed  in  character  by  the 
action  of  the  intestinal  juices,  as  has  been  pointed  out.  The  diagnosis 
may  be  aided  by  a  study  of  the  haemorrhage,  the  part  discharged  by 
vomit  having  the  characteristics  of  hsematemesis,  that  passed  by  stool 
presenting  the  appropriate  changes.  As  regards  treatment  of  ulcer  of 
the  duodenum,  the  plan  proposed  for  gastric  ulcer  is  applicable.  (See 
Ulcer  of  the  Stomach.)  Ulcers  similar  in  character  to  the  duode- 
nal, but  due  to  those  alterations  of  the  vessels  which  occur  in  amyloid 
degeneration,  are  occasionally  found  in  other  parts  of  the  small  intes- 
tines. The  symptoms  are  obscure,  and  the  diagnosis  a  mere  matter  of 
suspicion.  The  patient  affected  with  an  u.lcer  of  this  kind  suffers  with 
the  changes  wrought  by  amyloid  degeneration,  in  the  liver,  kidney, 
spleen,  and  other  organs.  There  are  emaciation,  pallor,  cedema,  diar- 
rhoea, etc.,  and  there  maybe  soreness  in  a  particular  locality,  and  hem- 
orrhage, to  indicate  the  nature  of  the  intestinal  disease,  but  obviously 
these  are  far  from  conclusive.  The  general  condition  is  the  point 
to  which  attention  must  be  directed  in  these  cases,  yet  no  subject  in 
therapeutics  is  more  unsatisfactory  than  the  amyloid  disease. 

The  Nature,  Symptoms,  and  Treatment  of  Ulcers  of  the  Csecum  and 
Appendix  Vermiformis. — Ulcers  in  these  situations  are  usually  of  me- 
chanical origin,  produced  by  the  retention  of  hardened  fseces,  by  the 
impaction  of  an  intestinal  or  biliary  calculus,  or  of  another  foreign 
body,  such  as  a  grape-seed,  a  cherry-seed,  a  pin,  etc.  These  foreign  bod- 
ies lodge  more  frequently  in  the  appendix  vermiformis,  but  they  may 
become  impacted  in  a  fold  of  the  mucous  membrane  of  the  csecum,  espe- 
cially of  the  posterior  wall,  for  this  has  a  fixed  position.  The  pressure 
of  the  foreign  body  excites  inflammation,  then  softening,  and  finally 
perforation.  The  position  of  the  ulcer  affects  the  result  enormously. 
If  it  perfoi'ate  the  posterior  wall  of  the  csecum,  which  is  not  covered 
by  the  peritoneum,  the  foreign  body  and  other  contents  of  the  bowel 
escape  into  the  loose  connective  tissue,  where  an  inflammation  ending 
in  an  abscess  is  set  up.  Then  the  history  is  that  of  fecal  abscess.  Oc- 
casionally a  primary  inflammation  develops  in  the  perica3cal  connective 
tissue,  an  abscess  forms,  and  a  communication  is  established  with  the 
bowel.  The  author  has  had  the  opportunity  to  study  a  case  of  this 
kind  which  lasted  two  years,  and  at  the  autopsy  a  large  pus-cavity  in  the 
iliac  fossa  behind  the  caecum  communicated  with  the  csecum  by  a  con- 
siderable orifice.  As  the  discharges  of  matter  through  the  bowel  had 
been  paroxysmal,  it  is  probable  that  the  original  opening  was  small. 


94  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

K  the  foreign  body  is  lodged  in  the  appendix,  inflammation  is  excited, 
and  a  perforating  ulcer  quickly  formed.  In  some  cases  the  whole  ap- 
pendix is  inflamed  and  converted  into  a  diffluent  mass.  As  the  ulcer 
extends,  the  peritoneum  is  quickly  reached.  One  of  two  results  must 
then  take  place  :  either  a  local  peritonitis  with  adhesions,  limiting  the 
mischief  to  that  locality,  or  a  sudden  rupture  into  the  general  cavity 
of  the  peritoneum.  If  the  process  is  slow,  the  peritoneum  forms  adhe- 
sions to  the  neighboring  surfaces  ;  if  rapid,  the  time  is  not  suflicient 
to  accomplish  the  task.  When  a  limiting  inflammation  is  thus  devel- 
oped, a  cavity  is  formed,  containing  the  matters  which  have  escaped 
from  the  appendix,  including  any  foreign  body  lodged  there,  fecal 
matters,  sloughs  of  the  ulcerated  surface,  serum,  and  pus.  In  a  short 
time  the  process  of  extrusion  begins,  the  pus  makes  its  way  downward 
under  Poupart's  ligament,  along  the  sheath  of  the  femoral  vessels,  and 
points  in  the  usual  situation.  In  two  thirds  of  the  cases  the  purulent 
collection  takes  this  direction  ;  in  others  it  points  over  the  crest  of  the 
ilium,  and  posteriorly,  in  the  lumbar  region.  Besides  the  ulcers  of 
merely  mechanical  origin,  the  caecum  is  the  seat  of  that  form  of  ulcer 
known  as  the  catarrhal — a  fact  which  the  author  believes  he  was  the 
first  to  demonstrate.*  It  is  a  fortunate  circumstance  that  these  catar- 
rhal ulcers,  which  have  such  a  strong  tendency  to  perforate  the  bowel, 
are  usually  situated  on  the  posterior  wall ;  doubtless  in  accordance 
with  the  now  well-known  law  that  those  parts  most  exposed  to  injury 
in  the  performance  of  their  functions  are  also  most  liable  to  disease. 
In  the  article  on  "  Typhlitis,"  the  symptomatology  and  treatment  are 
the  same  as  for  ulcer,  and  indeed  there  is  no  well-marked  distinction 
between  them  clinically,  except  it  may  be  the  vague  symptoms  of  ulcer 
which  precede  the  perforation  for  an  indefinite  period.  The  rectum  is 
also  the  seat  of  ulceration  of  the  catarrhal  type.  This  has  already 
been  pointed  out,  and  its  symptomatology  demonstrated,  but  more  fre- 
quently ulcers  of  the  rectum  have  a  mechanical  origin,  are  brought  on 
by  impacted  fseces,  the  lodgment  of  a  fish  or  other  bone,  of  seeds,  etc. 
Perforation  ensues,  an  abscess  is  formed,  which  points  alongside  the 
rectum,  in  the  perineum  and  elsewhere,  leaving  troublesome  "fistulre. 
An  ulcer  of  the  rectum,  healing,  may  produce  narrowing  and  deformity 
of  the  bowel,  seriously  impairing  its  functions.  But  these  ulcers  of 
the  rectum  do  not  heal  readily,  for  obvious  reasons — the  frequent  mus- 
cular movements,  the  passage  of  rough  matters  over  them,  the  con- 
stant presence  of  irritating  solids,  fluids,  and  gases. 

As  regards  the  treatment  of  ulcer  of  the  rectum,  there  are  two 
points — to  keep  the  bowels  soluble  without  frequent  motions,  and  to 
make  topical  applications  of  the  solid  nitrate  of  silver.  To  this  might 
be  added  a  third — stretching  the  sphincter.     This  can  be  done  by  a 

*  "  On  Typhlitis  and  Perityphlitis,"  "  Amer  Jour,  of  Med.  Sci.,"  October,  1866,  p.  351. 


ULCERS   OF   THE   INTESTINES.  95 

bivalve  rectal  speculum,  working  with  a  screw,  when  the  parts  are 
exposed  for  the  applications  to  the  surface  of  the  ulcer. 

The  Nature,  Symptoms,  and  Treatment  of  Tuberculous  Ulcers. — 
Ulcers  of  tubercular  origin  are  not  limited  to  any  anatomical  division 
of  the  intestine,  but  they  occur  most  frequently  in  the  lower  end 
of  the  ilium,  to  which,  indeed,  they  may  be  entirely  confined.  They 
may  occupy  the  whole  extent  of  the  mucous  membrane  from  the  stom- 
ach to  the  rectum  ;  they  may  be  confined  to  the  cajcum,  appendix, 
and  colon. 

The  deposit  of  miliary  tubercle  takes  place  in  the  follicles,  which 
become  crowded  and  obstructed,  so  that  the  cells  undergo  fatty  degen- 
eration and  atrophy.  The  miliary  tubercle,  in  preparation  for  extru- 
sion, becomes  caseous,  softens,  and  carries  with  it  the  surrounding 
textures,  thus  forming  an  ulcer,  which  widens  by  the  addition  of  new 
miliary  tubercle,  destined  to  undei'go  the  same  process  of  caseation, 
softening,  and  extrusion.  The  situation  of  the  ulcers  has  reference 
chiefly  to  the  distribution  of  the  vessels,  which  is  transversely,  and  on 
this  anatomical  fact  has  been  based  a  means  of  distinguishing  between 
tubercular  and  catarrhal  ulcers.  This  is  true  only  of  the  early  stage 
of  tbe  tubercle  deposit,  and  can  no  longer  be  depended  on  when,  as 
subsequently  happens,  the  formation  of  the  ulcers  takes  place  longitu- 
dinally also.  By  coalescence  their  form  is  greatly  altered.  The  exten- 
sion of  tubercle-ulcers  through  the  muscular  layer  of  the  bowel  is  very 
slow,  and  takes  place  chiefly  along  the  lymphatics,  ultimately  reaching 
the  peritoneum.  Indeed,  it  is  easy  to  trace  with  the  naked  eye  the 
tubercle-masses  crowding  the  lymph-vessels  and  the  lymph-spaces 
adjacent.  Deposits  then  cloud  the  peritoneum,  a  i^atchy  exudation 
forms,  and  adhesions  connect  the  neighboring  serous  surfaces,  and  so 
usual  is  this  result  that  perforation  by  a  tubercle -ulcer  is  rather  un- 
common. Tuberculosis  of  the  intestinal  mucous  membrane  is  a  local 
manifestation  of  a  general  state  ;  hence,  when  these  ulcers  exist  in  the 
intestines,  tubercular  deposits  will  be  found  elsewhere.  The  most  char- 
acteristic symptom  of  tubercular  ulcerations  is  an  obstinate  diarrhoea, 
wbich  resists  every  means  of  treatment,  and  is  only  palliated.  The 
stools  are  usually  yellowish,  are  very  thin,  and  contain  pus,  small 
sloughs  of  the  mucous  membrane,  etc.,  and  are  very  fetid  in  odor. 
Colicky  pains  attend  them,  and  tenesmus  also,  when,  as  is  frequently 
the  case,  the  rectum  is  involved.  The  stools  contain  also  small,  whit- 
ish lumps  (sago-grains),  masses  of  mucus  extruded  fi'om  those  spaces 
which  had  contained  the  follicles.  Clots  of  blot,  an  admixture  of  pus 
and  blood,  and  of  liquid  faeces  and  blood,  are  also  contained  in  the 
evacuations.  The  approach  of  the  ulcers  to  the  peritoneal  surface  is 
recognized  by  the  increased  pain,  and  the  tenderness  to  pressure  at  vari- 
ous points.  The  general  condition  of  the  patient  is  highly  significant. 
Emaciation  proceeds  rapidly.     The  evening  temperature  is  high  (103' 


9f)  DISEASES   OF  THE   DIGESTIVE  SYSTEM. 

-105°  Fahr.),  and  the  fever  is  distinctly  septicsemic  in  type.  There  is, 
at  the  same  time,  pulmonary  mischief  going  on,  as  a  rule,  in  these  cases. 
Investigation  will  disclose  the  fact  that  an  hereditary  tendency  exists. 
The  treatment  consists  in  the  use  of  opium  and  astringents,  vegetable 
and  mineral.  In  the  course  of  treatment  of  an  ordinary  case,  all  the 
resources  of  the  materia  medica  in  remedies  of  this  kind  will  be 
exhausted.  Under  the  heading  of  "  Intestinal  Catarrh  "  will  be  found 
some  remarks  on  treatment  equally  applicable  in  this  malady, 

CANCER  OF  THE  INTESTINES. 

Forms  and  Site. — The  three  forms — scirrhus,  medullary,  and  col- 
loid— which  affect  the  stomach,  occur  also  in  the  intestines.  As  has 
been  stated  already  in  regard  to  cancer  of  the  stomach,  the  origin  of 
the  neoplasm  is  epithelial,  and  the  initial  change  (always,  however, 
preceded  by  a  pronounced  local  hypersemia)  is  a  proliferation  of  the 
cells  of  the  follicles.  The  new  cells  extend  downward  and  develop  in 
greatest  abundance  in  the  submucous  layer.  The  growth  takes  an 
annular  direction,  and  in  the  contraction,  which  always  results,  the 
lumen  of  the  bowel  is  encroached  on  and  stenosis  produced.  As  is 
always  the  case,  those  parts  of  the  bowel  most  active  functionally,  and 
in  a  situation  to  be  most  readily  injured  in  the  performance  of  their 
functions,  are  most  apt  to  be  the  seat  of  cancer  ;  the  rectum,  the  cae- 
cum, and  the  flexures  of  the  colon,  are  these  parts. 

Cancer  of  the  intestine  is  usually  primary.  It  is  a  disease  of  ad- 
vanced life  (after  forty),  although  the  soft  variety,  the  medullary,  may 
occur  at  any  age. 

Symptoms. — There  are  three  symptoms  which  have  a  high  degree 
of  significance  :  pain  in  a  fixed  situation  ;  a  gradually  develoiDiug  ca- 
chexia ;  the  i^resence  of  a  tumor.  Until  these  symptoms  appear,  the 
diagnosis  will  be  largely  conjectural.  The  pain  is  at  first  a  mere  vague 
uneasiness  ;  gradually  a  sensation  of  soreness  with  some  tenderness  to 
pressure  is  developed,  and  finally  there  are  two  kinds  of  pain — a  dull, 
heavy,  tensive  soreness,  and  acute,  sharp,  lightning-like  pains.  The 
pain  may  radiate  somewhat  from  a  center,  but  the  most  important 
characteristic  of  the  cancer-pain  is  its  fixed  position.  From  the  mo- 
ment pain  is  felt  in  a  part  the  patient  declines  in  strength  and  weight, 
and  experiences  a  feeling  of  fatigue  quite  irrespective  of  any  exertion. 
The  complexion  slowly  changes,  until  ultimately  the  fawn-color  be- 
comes well  marked.  The  lips  are  then  bluish  white,  the  surface  dry 
and  scurfy,  the  skin  wrinkled,  the  hair  dry  and  dead-like.  In  cancer 
of  the  stomach  and  intestines  the  patients  usually  suffer  from  a  profuse 
salivary  flow  without  apparent  cause.  Sometimes  just  above  the  clavi- 
cle may  be  felt  enlarged  lymphatic  glands.  When  the  emaciation  has 
removed  the  fat  from  the  abdomen,  a  tumor  can  be  felt.     Although 


CANCER    OF   THE   INTESTINES.  97 

cancer  may  form  anywhere,  it  is  at  certain  points  wliere  we  may  ex- 
pect to  detect  a  tumor — the  points  of  election  ah-eacly  mentioned.  In 
six  cases  of  cancer  of  the  intestinal  canal,  observed  by  the  author  with 
special  reference  to  this  account  of  the  disease,  there  were  two  of  the 
rectum,  two  of  the  csecum,  one  at  the  sigmoid  flexure,  and  one  at  the 
angle  of  the  transverse  and  descending  colon.  If  the  tumor  is  scirrhus, 
it  is  felt  as  a  hard,  nodular  mass  ;  if  encephaloid,  an  irregular  growth, 
partly  hard  and  partly  elastic  ;  if  colloid,  a  more  diffused,  less  irregu- 
lar and  softer  mass,  not  well  defined.  Very  great  mistakes  are  made 
as  to  the  size  of  a  tumor,  or  indeed  as  to  its  presence,  in  cases  of  can- 
cer. As  the  stenosis  increases,  accumulations  take  place  behind  the 
point  of  narrowing,  and  then  hard  lumps  of  faeces  may  easily  be  con- 
founded with  a  nodular  tumor.  Subsequently  the  passage  of  the 
faeces  will  give  a  very  different  impression,  and  the  real  tumor  may  be 
detected  with  difficulty  or  not  at  all.  The  author  has  observed  this 
state  of  things  in  cancer  of  the  caecum  and  of  the  flexures.  The  symp- 
tomatology of  intestinal  cancer  varies  with  the  site  of  the  neoplasm. 
When  situated  at  the  ciecum,  pain  is  felt  in  the  right  iliac  fossa  ;  there 
the  tumor  may  be  detected,  and  there  the  patient  experiences  the  sen- 
sations due  to  the  passage  of  gas  and  faeces  through  a  narrowed  orifice. 
Large  accumulations  of  lumps  of  fgeces  and  gas  may  occur  at  times, 
presenting  the  appearance  of  a  large  tumor,  and  may  disappear  spon- 
taneously in  a  day  or  two,  or  be  made  to  disappear  by  gentle  pressure 
and  friction,  when  they  pass  through  the  orifice  with  a  sensation  of 
burning  pain  to  the  patient  and  with  gurgling  quite  audible  to  those 
around.  The  same  phenomena  occur  at  the  flexures  when  cancer  is 
developing.  In  the  rectum  there  is  severe,  burning  pain,  of  a  most 
agonizing  kind,  whenever  the  bowels  are  moved,  or  indeed  in  sitting 
or  standing  long,  and  pains  radiate  through  the  hips,  thighs,  and 
testes.  Usually  tenesmus  is  present,  and  a  constant  desire  to  go  to 
stool,  when  every  attempt  at  defecation  causes  unendurable  pain,  so 
that  the  patient,  if  possible,  postpones  the  painful  act  as  long  as  he 
can.  The  exploration  of  the  rectum  by  the  finger  will  furnish  valuable 
information  :  hard  nodules  will  be  encountered,  and  masses  may  be 
detached  from  the  ulcerating  surface  for  microscopic  examination.  In 
one  case  the  author  found  protrusion  of  the  rectum,  and  cancer-masses 
projecting  through  the  anus,  while  the  surrounding  tissue  (the  rectal 
fossae)  were  covered  over  with  enlarged  veins  and  filled  with  nodes  of 
stony  hardness.  The  least  attempt  at  exploration  caused  intolerable 
anguish,  and  the  passage  of  faeces  was  accomplished  by  no  less  suffer- 
ing. The  stools  at  first  only  indicate,  if  they  are  solid,  that  they  were 
forced  through  a  narrowed  orifice  ;  they  may  be  loose  or  constipated. 
In  the  progress  of  the  cases,  mucus,  muco-pus,  pus  and  blood,  foul- 
smelling  gangrenous  masses,  and  parts  of  the  neoplasm,  successively 
appear  and  mark  the  stages  in  the  growth  of  the  cancer,  With  the 
7 


98  DISEASES   OF  THE   DIGESTIVE   SYSTEM. 

increasing  stenosis  the  bowels  are  less  completely  emptied  ;  great  accu- 
mulations finally  take  place  ;  and,  ultimately,  death  may  he  brought 
about  by  the  protracted  constipation.  When  cancer  is  situated  in  the 
first  part  of  the  duodenum,  it  will  finally  be  accompanied  by  jaundice 
and  the  symptoms  of  gastric  cancer  at  the  pylorus,  so  that  it  will  be 
impossible  to  diagnosticate  its  position  correctly — a  failure  of  little 
moment. 

Rupture  of  the  intestine  may  be  caused  by  an  extension  of  the 
growth  to  the  peritoneum. 

Course,  Duration,  and  Termination. — Cancer  goes  on  steadily  to  a 
fatal  termination,  with  now  and  then  some  delusive  ajapearances  of 
improvement.  The  course  and  duration  vary  somewhat  with  age, 
powers  of  resistance,  and  situation  of  the  neoplasm.  Cancer  of  the 
colon,  unless  it  develops  in  a  way  to  cause  obstruction  of  the  bowel  at 
an  early  period,  is  not  so  quickly  fatal  as  cancer  of  the  csecum.  Can- 
cer of  the  duodenum  interferes  so  much  with  digestion  and  assimila- 
tion, and  with  the  hepatic  functions,  that  it  causes  death  by  exhaustion 
comparatively  early,  A  severe  haemorrhage  from  cancer  in  any  sit- 
uation may  determine  a  fatal  result.  The  duration  varies  according 
to  the  mode  of  termination  ;  from  one  to  three  years  may  be  regarded 
as  the  range.  The  termination  may  be  by  haemorrhage,  by  perforation 
and  peritonitis,  by  exhaustion,  or  by  an  intercurrent  disease — as  pneu- 
monia, pleuritis,  pericarditis,  etc. 

Diagnosis. — When  there  is  no  pain,  but  a  feeling  of  uneasiness,  no 
tumor  has  formed,  no  cachexia  developed,  a  diagnosis  will  be  impos- 
sible. From  catarrh  and  ulcer  of  the  intestines,  cancer  is  to  be  differ- 
entiated by  the  age  of  the  subject,  the  presence  of  a  tumor,  and  the 
gradual  appearance  of  a  cachexia.  The  tumor  of  cancer  may  be  con- 
founded with  floating  kidney,  aneurism,  fecal  accumulations,  and  other 
growths.  Floating  kidney  is  a  movable  tumor,  felt  in  different  posi- 
tions, in  which  there  may  be  occasional  bowel  attacks  but  no  persistent 
disease,  and  there  is  no  cachexia.  Aneurism  is  a  pulsating  tumor,  with 
an  expansile  movement,  and  the  pulsation  in  one  or  both  f  emorals  is 
retarded  by  it  and  altered  in  character.  An  apparent  pulsation  is  im- 
parted to  a  cancer  of  the  colon  by  lying  over  the  aorta  ;  but,  if  moved 
away  by  external  palpation,  or  by  a  change  in  the  position  of  the 
patient,  the  pulsation  ceases,  and  at  no  time  are  the  f emorals  affected. 
A  cancer  of  the  crecum  and  of  the  sigmoid  flexure  may  also  come  into 
relation  to  aneurism  of  the  iliac  arteries.  The  same  rules  apply  as 
above  given. 

A  fecal  tumor  with  colic  may  cause  the  merely  local  symptoms  of 
cancer  ;  but  the  history  of  the  case,  it  may  be  the  age  of  the  subject, 
will  decide,  and  the  cachexia  will  be  wanting.  The  use  of  purgatives 
will  settle  the  question. 

Prognosis. — No  means  are  now  known  by  which  cancer  can  be 


INTESTINAL   HEMORRHAGE.  99 

arrested  in  its  course,  much  less  cured,  so  that  the  prognosis  is  entirely 
unfavorable. 

Treatment. — Although  there  are  no  curative  measures  to  be  under- 
taken, much  can  be  done  to  alleviate  the  distresses  of  the  unfortunate 
subjects.  The  most  easily  digested  food,  and  the  varieties  which  can 
be  utilized  by  the  digestive  organs  without  leaving  any  residuum, 
should  be  directed.  The  bowels  should  be  kept  in  a  soluble  state  to 
prevent  accumulations,  and  to  avoid  friction  of  the  hardened  faeces  on 
an  irritable  surface.  To  relieve  the  pain  anodynes  become  necessary, 
but  the  physician  must  carefully  guard  their  administration,  owing  to 
the  enormous  quantity  which  the  patient  will  use  if  left  to  his  own 
inclination.  The  author  must  repeat  the  statement  which  he  has 
already  made  in  regard  to  the  utility  of  arsenic  in  cancer  to  relieve 
pain  and  retard  the  growth. 

INTESTINAL  H.E3MORRHAGE. 

Causes,  Symptoms,  and  Diagnosis. — The  subject  of  gastric  hgemor- 
rhage,  which  has  been  fully  treated,  is  occupied  with  the  same  ques- 
tions, except  the  difference  in  position,  as  intestinal  haemorrhage  ;  and 
therefore  only  a  comprehensive  but  concise  statement  is  necessary  here. 

Haemorrhage  from  the  intestines  arises  from  all  those  morbid  states 
which  increase  the  blood-pressure  in  the  portal  system — as  obstructive 
diseases  of  the  heart  and  great  vessels,  of  the  lungs,  and  of  the  liver, 
especially  ;  from  rupture  of  the  vessels  themselves  occurring  in  the 
various  kinds  of  ulceration  of  the  mucous  membranes,  and  from  mor- 
bid states  of  the  blood  itself,  as  purpura,  etc.  The  symptoms  produced 
by  an  intestinal  haemorrhage  will  vary  with  the  immediate  cause,  with 
the  amount  of  blood  lost,  and  with  the  condition  of  the  patient  at  the 
time.  If  considerable,  the  face  becomes  deadly  pale,  the  eyes  glassy  ; 
there  is  a  rushing  and  roaring  in  the  ears  ;  the  pulse  becomes  weak,  or 
ceases  at  the  wrist  ;  consciousness  is  lost,  and  a  convulsive  shudder 
passes  through  the  muscular  system,  and  death  may  ensue,  without  any 
escape  of  blood  externally  :  or  there  may  be  mere  faintness,  and  con- 
sciousness not  lost ;  a  sudden  and  irresistible  desire  to  have  an  evacu- 
ation of  the  bowels  is  felt,  and  blood  in  clots  and  partly  fluid,  or  a 
blackish,  semifluid,  tarry  mixture  may  be  passed.  When  the  haemor- 
rhage is  from  the  descending  colon,  the  blood  discharged — if  passed 
immediately — is  unaffected  by  the  intestinal  juices,  but,  if  it  come  from 
a  point  high  up  in  the  small  intestines,  it  will  appear  as  an  homogeneous, 
tarry  fluid,  but  may,  of  course,  be  mixed  with  faeces.  When  the  blood 
escapes  in  small  quantity,  and  slowly,  there  will  not  be  any  systemic 
evidences  of  the  loss,  except  a  slowly  developing  anaemia,  and  the  ap- 
pearance of  the  blood  in  the  stools  will  take  place  in  the  form  already 
described.    When  the  blood  escapes  from  the  rectum  it  may  be  passed 


100  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

before,  with,  or  after  the  fseces,  which  may  be  covered  with  blood,  but 
are  not  mixed  with  it.  The  rectum  offers  great  facility  for  the  deter- 
mination of  the  source  of  the  htemorrhage,  and  an  examination  will 
show  whether  the  bleeding  is  from  hsemorrhoids  or  from  an  ulcerated 
surface.  "When  an  ulcer  of  the  rectum  exists,  the  passage  of  the  faeces 
will  cause  some  blood  to  flow,  which  will  often  be  found  on  the  top  of 
the  faeces,  together  with  some  pus.  The  importance  of  intestinal 
haemorrhage  will  depend,  first,  on  the  nature  of  the  malady  which  is 
its  cause  ;  and,  second,  on  the  amount  of  blood  lost.  If  typhoid,  or 
cancer,  for  example,  the  importance  of  the  haemorrhage — unless  itself 
sufficient  to  cause  death — is  merged  comj^letely  in  the  importance  of 
the  malady  associated  with  it. 

Treatment. — In  the  remedial  management  of  intestinal  haemorrhage, 
the  same  principles  and  methods  are  applicable  as  were  recommended 
in  the  cognate  disease — gastric  haemorrhage.  The  most  absolute  quiet 
must  be  maintained,  mustard-plasters  and  ice-bags  applied  to  the  abdo- 
men, ergotin  injected  subcutaneously,  alum-whey  drunk  freely.  If 
time  is  afforded,  the  usual  iron  styptics  can  be  administered  by  the 
stomach,  or  if  the  source  of  the  haemorrhage  is  low  down  they  can  be 
administered  more  efficiently  by  the  method  of  irrigation  or  by  ene- 
mata.  The  author  has  known  of  an  instance  of  fatal  haemorrhage 
induced  by  an  injection  of  a  solution  of  Monsel's  salt,  given  to  arrest 
a  haemorrhage — caution  is  therefore  necessary.  An  intestinal  haemor- 
rhage is  a  mere  symptom  ;  the  treatment  of  it  is  necessarily  a  part  of 
the  disease  with  which  it  is  associated.  If  it  occur  during  the  course 
of  typhoid,  very  different  management  will  be  requisite  from  that 
necessary  in  purpura,  or  in  cirrhosis,  etc.  Only  general  rules  can 
therefore  be  indicated  here. 


ENTERALGIAs   NEURALGIA  OF  THE   INTESTINES— COLIC. 

Deflnition. — The  term  enteralgia  is  applied  to  a  neuralgia  of  the 
intestines,  of  a  functional  character,  and  is  therefore  a  neurosis,  and 
should  be  studied  with  the  group  of  neuroses,  but  it  is  convenient  to 
take  it  up  at  this  ]3oint. 

Causes,  Symptoms,  and  Diagnosis. — Except  for  the  difference  in 
site,  the  story  of  gastralgia  might  be  repeated  here.  A  more  con- 
densed description  than  would  otherwise  be  proper  will  now  suffice. 

The  causes  of  this  affection  can  be  comprehended  in  two  groups  : 
an  irritable  state  of  the  nerves  themselves  ;  irritation,  by  various 
objects,  of  the  terminal  filaments  of  the  nerves  (end-organs)  in  the 
mucous  membrane  of  the  intestinal  canal.  In  the  first  group  must  be 
placed  that  condition  of  the  nervous  system  existing  in  hysteria,  hypo- 
chondriasis, and  in  the  various  cachexiae — paludal,  plumbic,  cupric, 
syphilitic,  etc. ;  and  in  the  second,  improper  food,  coarse  and  irritant 


ENTERALGIA.  101 

articles,  as  husks  of  grain,  seeds  of  fruits,  etc.  ;  hardened  faeces,  im- 
pactions of  faeces,  fermentation  and  flatulent  distention  of  the  bowels  ; 
cold,  etc. 

An  attack  of  colic  may  come  on  gradually  with  a  feeling  of  uneasi- 
ness in  the  bowels,  some  nausea,  eructations  of  gas,  etc.,  or  it  may  be- 
gin abruptly  and  develop  full  force  at  once.  When  it  occurs  by  either 
mode,  there  is  felt  about  the  umbilicus  a  peculiarly  severe  and  depress- 
ing pain,  having  the  well-known  griping  quality.  There  are  number- 
less gradations  in  the  severity  of  the  attacks,  from  a  little  griping  pain 
felt  for  a  few  minutes,  up  to  a  seizure  of  such  severity  that  the  patient 
may  appear  as  if  collapsed.  In  any  case  of  moderate  severity,  the  suf- 
fering during  the  time  the  attack  lasts  is  great — the  patient  groans  or 
cries  with  anguish,  the  body  is  doubled  up,  and  the  lists  are  pressed 
deeply  in  the  abdomen,  or  the  abdomen  is  lain  upon  with  the  whole 
weight.  Meanwhile  the  pulse  is  small  and  weak,  the  surface  cool  or  cold, 
the  face  has  an  anxious  and  suffering  expression,  and  is  covered  with  a 
cold  sweat.  The  abdomen  may  be  hard  and  tympanitic  or  retracted, 
and  occasionally  tender,  instead  of  pressure  giving  relief.  The  kid- 
neys secrete  a  large  quantity  of  pale  urine,  and  a  frequent  desire  to 
micturate  is  usually  felt.  Vomiting  generally  occurs,  and  affords  some 
relief,  but  an  action  of  the  bowels,  which  is  always  sought  for,  removes 
all  the  pain,  at  least  for  the  time.  Sometimes  the  attack  terminates  by 
a  discharge  of  flatus,  by  eructation  or  by  the  bowels,  and  then  relief  is 
experienced. 

The  duration  of  the  attacks  is  variable — they  last  from  a  half  hour 
to  several  hours,  and  a  succession  of  attacks  is  not  unusual,  carry- 
ing the  case  on  for  several  days.  When  the  attacks  are  plumbic, 
the  colic  is  known  as  dry,  and  obstinate  constipation  is  a  prominent 
symptom — the  pain  continuing  until  this  is  removed.  The  history  of 
the  individual,  his  occupation  as  a  painter,  and  the  behavior  of  the  case 
itself,  will  indicate  the  nature  of  the  attack.  When  it  is  paludal  (mala- 
rious), the  attacks  will  be  distinctly  periodical.  If  syphilitic,  the  pain 
will  occur  in  the  evening,  and  leave  the  patient  unmolested  during  the 
day.  The  duration  of  those  cases  having  their  origin  in  a  cachexia 
will  depend  on  the  treatment ;  for,  if  the  underlying  morbid  cause  fail 
to  be  recognized,  they  may  be  prolonged  indefinitely. 

Enteralgia  may  at  once  be  distinguished  from  all  inflammatory 
affections  by  the  absence  of  fever,  and  of  tenderness  on  pressure,  and 
by  the  early  termination  of  the  seizure,  leaving  the  status  in  quo.  It 
is  distinguished  from  gastralgia  by  the  situation  of  the  pain,  and  by 
the  relief  obtained  by  an  escape  of  flatus  and  by  an  evacuation  of  the 
bowels,  instead  of  by  vomiting.  It  is  distinguished  from  hepatic  colic 
by  the  seat  of  the  pain  in  the  latter,  by  the  tenderness  over  the  gall- 
bladder, by  the  appearance  of  bile-pigment  in  the  urine,  and  afterward 
of  jaundice.     It  is  distinguished  from  nephritic  colic  by  the  following 


102  DISEASES   or   THE   DIGESTIVE   SYSTEM. 

symptoms  which  indicate  the  latter  :  by  the  pain  along  the  course  of 
the  ureter,  by  the  pain  in  and  retraction  of  the  corresponding  testicle, 
by  the  strangury  and  bloody  ui-ine,  etc. 

The  colic  of  gaseous  accumulation  is  differentiated  from  the  other 
forms  by  the  fullness  and  tympanitic  distention  of  the  abdomen,  and 
by  the  passage  of  gas  in  both  directions.  This  is  the  colic  of  infants. 
The  colic  of  fecal  accumulation  is  recognized  by  the  fullness  of  some 
particular  part,  and  the  occurrence  of  pain  in  the  same  locality,  fre- 
quently the  csecum  and  ascending  colon,  and  at  the  sigmoid  flexure. 
The  colic  of  lead  is  aasociated  with  the  lead-cachexia,  with  pallor  and 
anaemia,  with  a  blue  line  along  the  margin  of  the  gum,  with  a  slow 
pulse,  with  a  retracted  abdomen,  etc.  The  enteralgia  of  chronic  ma- 
larial poisoning  is  known  by  its  prompt  occurrence  at  a  fixed  time,  as 
has  been  pointed  out. 

The  prognosis  is  favorable  in  genuine  colic. 

Treatment. — The  important  point  is  to  remove  the  cause  which 
gives  rise  to  the  disturbance — if  some  irritant  matters  or  fecal  accu- 
mulation, an  active  purgative  is  indicated.  The  flatulent  colic  of 
infants  is  quickly  and  safely  relieved  by  the  bromide  of  potassium  and 
oil  of  anise  in  an  emulsion — five  grains  of  the  former  and  the  eighth 
of  a  drop  of  the  latter,  every  half  hour  until  relieved.  For  the  im- 
mediate relief  there  is  no  remedy  comparable  to  the  hypodermatic 
injection  of  morphia  and  atropia.  By  relaxing  spasm,  the  injection 
favors  the  action  of  laxatives  or  purgatives.  For  the  treatment  of  the 
colic  of  some  cachexise,  the  appropriate  remedies  for  the  cachexia  will 
be  necessary :  for  example,  quinia  in  intermittent  colic,  iodide  of 
potassium  in  nocturnal  colic,  and  alum  in  lead-colic.  For  the  hysteri- 
cal colic,  a  combination  of  Hoffman's  anodyne  and  fluid  extract  of 
valerian  is  effective.  Enemata  of  asaf cetida  mixture  may  also  be  used. 
For  chronic  enteralgia  of  the  bowel — an  extremely  obstinate  affection 
— arsenic,  probably,  stands  in  the  front  rank.  The  neuralgiae  are, 
however,  considered  more  fully  in  another  place,  to  which  the  reader 
is  referred. 

OBSTRUCTION  OF  THE   INTESTINES. 

Definition. — By  obstruction  or  occlusion  of  the  intestines  is  meant 
an  arrest  of  the  passage  of  their  contents,  by  obstacles  within  the  bowel, 
or  in  its  walls,  or  in  the  cavity  of  the  peritoneum.  When  the  obstruc- 
tion occurs  in  the  intestine  after  it  has  passed  out  of  the  cavity — as 
strangulated  hernia,  for  example — it  becomes  a  surgical  malady.  A 
great  many  names  have  been  applied  to  this  state  :  ileus,  iliac  passion, 
volvulus,  miserere,  etc. 

Causes. — Obstruction  or  occlusion  of  the  intestines  may  be  pro- 
duced by  causes  that  are  intrinsic,  or  extrinsic,  but  they  are  best  con- 
sidered in  three  great  divisions  :  1.  Extrinsic,  or  entirely  outside  of  the 


OBSTRUCTION   OF   THE   INTESTINES. 


103 
3.   Dis- 


bowel  ;   2.  Conditions  affecting  the  walls  of  the  intestines 
orders  within  the  canal. 

1.  The  extrinsic  causes  are  tumors  without  compressing  the  intes- 
tine ;  certain  orifices  in  the  peritoneum,  as  the  foramen  of  Winslow  ; 
bands  of  connective  tissue,  remains  of  former  inflammation  ;  twisting, 
or  torsion,  of  the  bowel. 


Fio.  1.— The  above,  from  Ziemssen's  "  Cyclopaedia," 
illustrates  the  modo  in  which  torsiOD,  or  twisting, 
is  effected. 


Fig.  2. — Con.strietionhyahand 
of  lymph  (Ziemtisen). 


The  tumors  coming  into  relation  with  the  intestine,  and  obstruct- 
ing by  pressure,  are  of  various  kinds  :  floating  kidney,  displaced  spleen, 
cysts  of  the  peritoneum,  tumors  of  the  mesentery,  of  the  ovary,  etc., 
and  cancer  in  various  situations.  As  regards  the  entanglement  of  the 
bowel  by  passing  into  certain  orifices,  especially  the  foramen  of  Wins- 
low,  the  accident  is  rare  (three  cases  recorded),  but  a  number  of  ex- 
amples have  now  been  noted  of  retro-peritoneal  hernia,  first  accurately 
described  by  Treitz.*  The  duodeno-jejunal  flexure  is  embraced  in  a 
fossa  formed  by  a  fold  of  peritoneum,  "  continuous  on  its  inner  side 
with  the  peritoneum  covering  the  transverse  duodenum,  and  forming 
the  inferior  layer  of  the  transverse  mesocolon."  Diaphragmatic  her- 
nia is  relatively  more  common  ;  Leichtenstern  collected  two  hundred 
and  fifty-two  cases.  There  are  certain  weak  points  in  the  diaphragm 
— at  the  oesophageal  foramen,  just  behind  the  sternum,  the  space  be- 
tween the  lumbar  and  costal  parts  of  the  muscle  of  the  diaphragm — 
through  which  parts  of  the  bowel  and  omentum  have  passed. 

Constriction  by  old  bands  of  adhesion,  the  result  of  former  inflam- 
mations, is  much  more  common  than  the  herniary  protrusions.  The 
adhesion  of  the  appendix  vermiformis  to  the  abdominal  wall,  or  to 
neighboring  parts  of  the  intestine,  forms  a  transverse  band  in  which  a 
knuckle  of  intestine  may  become  engaged.  Similar  bands,  or  bridges, 
form  between  the  organs  in  the  pelvic  cavity,  and  between  the  mes- 
entery and  intestine.  Some  of  these  bands,  owing  to  changes  made 
by  the  movements  of  organs,  often  quite  considerable,  attain  to  great 


*  Dr.  P.  H.  Pje-Smitb,  "Guy's  Ilospital  Reports,"  thii'd  series,  vol.  xvi,  p.  131,  "  On 
Retro-peritoneal  Hernia." 


104:  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

lengths  and  form  constricting  loops  of  Various  kinds.  Slits  are  found 
in  the  mesentery,  especially  in  the  mesentery  of  the  ilium,  and  low 
down,  into  which  a  fold  of  the  intestine  may  drop  and  become  incar- 
cerated. The  extremity  of  diverticula  becoming  attached  by  bands 
of  lymph,  also  form  openings  into  which  the  intestine  may  pass. 
There  is,  indeed,  almost  no  limit  to  the  forms  and  varieties  of  con- 
stricting bands  for  the  incarceration  of  some  part  of  the  intestine. 

Occlusion  may  be  brought  about  by  twisting  (torsion)  of  the  bow- 
els. The  sigmoid  flexure  is  especially  liable  to  this  accident,  owing  to 
its  shape  and  to  congenital  defects,  and  next  the  csscum  ;  rarely  does 
this  accident  happen  to  any  other  part  of  the  canal.  In  the  prelimi- 
nary changes  which  occur  in  the  sigmoid  flexure  preparatory  to  tor- 
sion, the  mesenterial  root  shrinks  and  the  two  ends  of  the  fold  approxi- 
mate, so  that  twisting  can  easily  occur  if  the  peripheral  part  of  the  fold 
is  full  of  faeces  and  therefore  heavy.  The  length  and  weight  of  the 
fold  prevent  untwisting,  while  rapid  swelling  and  distention  by  gas, 
occurring  in  that  part  6f  the  bowel  above,  keep  the  fold  in  position.* 

While  twisting  of  the  sigmoid  flexure  is  apt  to  take  place  in  early 
life,  torsion,  or  twisting,  of  the  caecum  is  a  malady  of  advanced  life 
rather — in  more  than  half  of  the  cases  occurring  from  forty-five  to  sixty 
years.  Owing  to  the  changes  produced  by  old  hernias,  to  the  absorp- 
tion of  fat  in  the  mesentery,  and  to  paresis  of  the  muscular  layer  with 
resulting  accumulation  of  faeces,  a  loop  of  the  caecum  and  ascending 
colon  forms — with  a  contracted  mesentery — the  axis  of  the  loop  ;  the 
two  ends  of  the  loop  approximate,  and  a  twist  may  be  readily  induced 
by  various  forces,  as  sudden  movements  of  the  body,  an  abnormally 
long  and  full  ilium,  etc. 

2.  Changes  occurring  within  the  intestinal  tunics,  such  as  tumors, 
polypi,  hj^datid  cysts,  carcinoma,  etc.,  cause  occlusion  by  a  gradual 
obliteration  of  the  canal.  More  frequently  is  the  obstruction  due  to 
cicatrices,  formed  by  the  closure  of  ulcers,  notably  those  of  dysentery, 
of  typhoid  fever,  of  syphilis,  etc.  The  most  important  of  this  group 
of  causes  is  intussusception.  By  this  term  is  meant  the  slipping  of 
one  part  of  the  intestine  into  the  adjacent  part,  so  that  the  peritoneal 
and  mucous  surfaces  are  opposed  to  each  other.  This  accident  always 
occurs  from  above  downward.  Frequently,  after  death,  there  are 
found  invaginations,  which  formed  during  the  last  moments  of  life, 
but  they  have  no  importance.  Often  a  number  of  them  exist  at  vai'i- 
ous  points. 

As  the  part  first  invaginated  remains  at  the  point  where  it  entered, 
it  is  obvious  that  the  increase  of  the  intussusception  is  by  a  continued 

*  Dr.  Kiittner,  in  St.  Petersburg.  Virchow's  "Arcliiv,"  vol.  xliii,  p.  478,  "Ueber  in- 
iiere  Incarccrationen."  A  full  account  of  the  subject,  with  admirable  plates  showing  the 
mechanism  of  twisting.  Ibid.,  Band  liv,  S.  34.  Also  in  the  same,  "  A  Case  of  Internal 
Strangulation,"  by  Jacob  Ileiberg,  with  two  illustrative  diagrams. 


OBSTRUCTIOX   OF   THE   INTESTINES.  105 

slipping-up  of  the  part  below.  The  accident  of  invagination  may  take 
place  at  any  point  of  the  intestines,  but  the  most  common  is  that  of 
the  ilium  into  the  caecum,  and  this  attains  the  greatest  dimensions.  In 
children  the  ilium  may  pass  into  the  whole  length  of  the  colon,  and  be 
felt  in  the  rectum  and  even  pass  through  the  anus.  Other  forms  are 
of  the  ilium  entirely,  of  the  jejunum  into  the  ilium,  of  the  duodenum 
into  the  jejunum,  of  the  colon,  etc.  Of  all  the  forms  of  obstruction  in 
the  intestinal  canal  occurring  in  early  life,  that  of  invagination  is  most 
usual.  Including  all  ages,  half  of  the  cases  of  intussusception  occur 
before  ten.  As  regards  sex,  males  are  more  subject  to  the  accident 
than  females.  There  are  two  important  elements  in  the  mechanism — 
pai'esis,  or  distention,  of  a  part  of  the  intestine  below  ;  spasm,  or  con- 
traction, of  the  part  above.  When  the  bowel  is  undergoing  irritation 
and  is  distended  with  gas,  if,  in  consequence  of  the  same  irritation, 
violent  reflex  contraction  of  the  circular  fibers  is  induced,  it  is  not  dif- 
ficult to  conceive  of  the  suddenly  narrowed  portion  dropping  into  the 
distended.  Especially  can  we  conceive  this  accident  happening  if  the 
muscular  layer  of  the  enlarged  portion  of  the  bowel  is  in  a  paretic 
state,  and  the  muscular  layer  in  the  narrowed  part  is  in  a  tetanic  or 
spasmodic  state.  A  different  explanation  of  the  mechanism  is  made 
by  others,  especially  by  Leichtenstern,  who  affirms  that  there  are  two 
factors  involved — a  paretic  condition  of  a  part  of  the  bowel ;  violent 
peristaltic  action.  He  supposes  that  the  invagination  occurs  entirely 
by  an  inversion  of  the  paretic  part  of  the  bowel,  and  that  this  inver- 
sion is  initiated  by  the  excited  peristaltic  action.  The  differences  of 
opinion  are  not  very  wide,  after  all,  and  are  rather  in  the  interpretation 
of  terms  than  of  the  pathological  factors.  When  intussusception  oc- 
curs at  the  caecum,  doubtless  the  same  causes  are  at  work  as  those 
which  induce  protrusion  of  the  bowel  in  dysentery — a  violent  tenes- 
mus with  paresis  of  the  muscular  layer — a  condition  of  things  which 
may  readily  arise  in  the  ilium  and  the  caecum.  When  invagination 
has  occurred,  the  mesentery  being  drawn  in  with  the  bowel  and  more 
or  less  stretched,  the  circulation  is  greatly  impeded,  especially  the 
return  of  venous  blood.  Swelling  ensues  ;  the  tunics  of  the  invagi- 
nated  portion  of  the  bowel  are  infiltrated  with  bloody  serum  ;  an 
active  catarrh  of  the  mucous  membrane  is  established  ;  and  the  peri- 
toneum becomes  intensely  hypertemic,  and  an  abundant  exudation  is 
poured  out,  gluing  together  the  contiguous  portions  of  mucous  mem- 
brane. In  these  cases  there  is  not,  necessarily,  a  complete  occlusion — 
there  may  be  still  space  for  the  passage  of  liquid  faeces.  The  com- 
pression of  the  mesenteric  vessels  induces  necrosis  of  the  invaginated 
portion,  which  may  slough  off,  and  thus  restore   continuity.*     It  is 

*  Trousseau,  "  Cliniquc  iledicale,"  tome  iii,  p.  196.     He  has  had  two  cases  of  this 
kind. 


106  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

necessary  to  this  result  that  the  invagination  be  equal  on  all  sides,  that 
union  take  place  in  a  uniform  manner  around  the  bowel.  If  the  invagi- 
nation is  unequal  and  the  line  of  union  irregular  after  the  slough 
weparates,  in  the  course  of  contraction  of  the  cicatrix  which  subse- 
quently takes  place,  there  may  be  produced  very  considerable  deform- 
ity of  the  intestine,  and  its  lumen  seriously  encroached  upon.  Again, 
when  the  slough  separates,  the  adhesion  may  be  insufficient,  thus  open- 
ing into  the  general  cavity  of  the  peritoneum. 

Causes  of  obstruction  within  the  canal  of  the  intestines  are  quite 
frequent — relatively  more  so  than  the  extrinsic  causes.  First  in  im- 
portance is  fecal  accumulation,  forming  most  frequently  in  the  caecum 
and  ascending  colon,  and  in  the  descending  colon  just  above  the  sig- 
moid flexure.  Not  unfrequently  such  fecal  accumulation  has  for  a 
nucleus  an  intestinal  or  biliary  calculus.  The  intestinal  calculi  are 
composed  of  ammoniaco-magnesian  phosphate,  and  the  carbonate  and 
phosphate  of  lime,  with  more  or  less  inspissated  mucus  (enteroliths). 
Other  foreign  bodies  accidentally  present  in  the  canal  may  form  a 
nucleus  about  which  the  salts  above  named  crystallize  or  adhere.  They 
are  usually  oval  in  shape,  but  may  have  a  great  variety  of  forms,  and 
they  differ  greatly  in  size,  the  average  being  about  the  size  of  a  chest- 
nut. Large  concretions  of  chalk  and  magnesia  have  formed  when 
these  substances  had  been  taken  medicinally  for  some  time.  Stones  of 
great  size  have  formed,  alone  sufficient  to  cause  obstruction.  The  usual 
results  of  their  presence,  if  they  occasion  symptoms,  are  attacks  of  in- 
testinal indigestion,  colic,  typhlitis,  ulceration,  and  perforation  of  the 
csecum  and  appendix.  Biliary  calculi  much  more  frequently  occasion 
obstruction  ;  although  of  considerable  size,  they  have  been  passed 
without  any  trouble.  Sometimes,  the  symptoms  of  acute  intestinal 
catarrh,  pain,  flatulence,  nausea,  diarrhoea,  etc.,  are  caused  by  them  ; 
again,  the  bowels  are  obstructed  more  or  less  completely  by  one,  or  a 
succession  of  attacks  of  impaction,  relief  from  one  attack  being  fol- 
lowed in  a  few  weeks  by  another  attack  of  the  same  character,  have 
been  produced  by  a  gall-stone,  lodging  successively  in  different  parts 
of  the  ilium.  Now  and  then  complete  obstruction  has  been  caused  by 
a  gall-stone.  They  occasionally  set  up  an  ulcerative  process  in  the 
caecum  and  appendix.  An  important  factor  in  causing  obstruction  of 
the  bowel  is  habitual  constipation — that  form,  especially,  which  con- 
sists in  a  paretic  condition  of  the  muscular  layer,  and  a  state  of  dimin- 
ished sensibility  of  the  mucous  membrane.  Abnormal  flexures  of  the 
colon  often  play  an  important  part  in  causing  an  obstinate  constipa- 
tion. Accumulations  occur  to  a  very  great  extent  behind  the  natural 
and  factitious  flexures,  and  in  the  caecum  in  old  subjects  especially,  in 
women  leading  very  sedentary  lives,  and  very  careless.  Large  accu- 
mulations are  not  incompatible  with  daily,  even  more  frequent  evacua- 
tions.    The  central  canal  may  still  continue  open  and  yet  enormous 


OBSTRUCTIOX  OF  THE  INTESTINES.  107 

masses  remain  in  the  sacculi.     Finally,  some  large  fecal  masses  drop 
into  the  canal,  and  symptoms  of  occlusion  at  once  appear. 

Symptoms. — The  cause  and  the  seat  of  the  occlusion  affect  some- 
what the  character  and  development  of  the  symptoms,  but  there  are 
certain  symptoms  common  to  all  forms  :  these  are  pain,  arrest  of  the 
intestinal  movements,  gaseous  distention  of  the  bowels,  and  vomiting. 
The  pain  is  not  acute  and  lancinating,  but  is  severe,  colic-like,  with  a 
feeling  of  soreness,  and  is  aggravated  by  pressure.  In  the  beginning 
the  pain  is  felt  about  the  umbilicus,  in  the  iliac  regions,  and  radiates 
thence  over  the  abdomen.  When  tenderness  to  pressure  exists  at  the 
outset,  it  is  indicative  of  the  seat  of  the  lesion,  but  the  tenderness  is 
rather  a  feeling  of  soreness,  and  has  not  the  painful  character  of  the 
tenderness  which  is  developed  later  on  when  peritonitis  appears.  It  is 
important  to  note  that  the  tenderness  and  pain  cease  when  collapse 
comes  on — for  the  author  has  known  this  to  be  mistaken  for  improve- 
ment. At  first,  and  usually  after  the  administration  of  an  enema,  there 
may  be  an  evacuation  from  the  lower  bowel,  and  this  is  often  a  source 
of  misapprehension,  for  it  is  assumed  that  the  canal  is  not  obstructed. 
It  may  be  regarded  as  an  evidence  that  the  obstruction  is  above  the 
sigmoid  flexure,  but  it  has  no  higher  significance  than  this.  At  the 
beginning  of  symptoms — of  intussusception,  for  example — some  liquid 
freces  may  escape,  but  presently  the  obstacle  to  the  passage  of  fecal 
matters  and  of  gas  is  complete.  Even  when  those  exceptional  dis- 
charges, just  referred  to,  escape,  there  is  no  improvem^ent  in  the  feel- 
ings or  condition  of  the  patient ;  they  do  not  diminish  the  fullness  and 
tension  of  the  abdomen.  When  complete  obstruction  has  existed 
twenty-four  to  forty-eight  hours,  the  abdomen  is  no  longer  soft  and 
flexible,  but  the  muscles  have  become  rather  rigid,  and  the  whole  ab- 
domen is  swollen  and  hard,  returning  on  percussion  a  note  of  tympa- 
nitic quality,  except  where  an  accumulation  of  faeces  gives  a  different 
tone.  In  the  further  progress  of  the  case,  more  and  more  gas  distend- 
ing the  intestines,  they  can  be  distinguished  as  inflated,  sinuous  cylin- 
ders :  the  small  intestines  filling  the  umbilical  space,  the  large  in- 
testine, the  flanks,  and  the  lower  epigastric  region.  ISTot  unfrequent- 
ly  the  abdomen  is  uniformly  distended,  the  highest  point  in  the  centre 
and  falling  off  in  all  directions,  and  the  walls  drawn  as  tense  as  the 
tightened  drum-head.  Besides  the  immediate  and  local  distress  thus 
occasioned,  the  functions  of  the  thoracic  organs  are  interfered  with  by 
the  upward  pressure.  The  respiration  is  thoracic,  oppressed,  and  hur- 
ried, a  distressing  hiccough  supervenes,  and  the  action  of  the  heart  is 
troubled.  Vomiting  is  a  most  characteristic  symj)tom  under  certain 
circumstances.  It  sometimes  begins  early,  immediately  after  the  ob- 
struction, and  consists  at  flrst  of  aliment,  then  of  mucus,  mucus  and 
gastric  juice,  mucus  and  bile  from  the  gall-bladder  forced  up  by  the 
straining.     On  the  other  hand,  vomiting  may  be  postponed  until  the 


108  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

signs  of  obstruction  are  well  advanced.  If  vomiting  persists,  presently 
the  matters  returned  consist  not  only  of  greenish  sero-mucus,  but  of 
the  contents  of  the  lower  ilium,  and  having  a  fecal  odor.  Indeed,  dis- 
tinctly formed  but  not  molded  faeces  have  been  returned  by  vomiting, 
but  usually  it  is  a  yellowish  fluid,  having  the  consistence  of  soup,  and 
an  odor  and  taste  sufficiently  definite.  The  fecal  vomiting  recurs  from 
time  to  time,  and,  if  it  well  empties  the  intestines  of  their  contents, 
the  abdominal  symptoms  are  improved  ;  there  is  much  less  distress, 
and  the  distention  is  diminished,  so  that  the  thoracic  organs  are  not  so 
embarrassed,  but  this  merely  local  improvement  does  not  help  the  case 
otherwise.  The  gravity  of  the  case  is  illustrated  in  the  systemic  con- 
dition, which  becomes  rapidly  bad.  There  is  no  fever,  but  a  tempera- 
ture below  rather  than  above  the  normal.  The  countenance  at  first 
expresses  great  anxiety,  then  becomes  contracted  and  drawn,  the  eyes 
deeply  sunken  and  surrounded  with  a  livid  circle,  the  nose  pinched  and 
blue,  the  lips  blue,  the  tongue  dry,  the  voice  husky  and  sepulchral,  the 
surface  of  the  body  generally  cold  and  covered  with  a  cold  sweat,  the 
skin  livid  and  wrinkled,  hiccough  persisting  and  more  and  more  har- 
assing, the  breathing  more  shallow  and  rapid,  the  temperature  declin- 
ing a  degree  or  two  Fahr. — such  is  the  complexus  of  symptoms  in  the 
approaching  collapse.  Usually  the  mind  is  clear  and  the  anxiety  great, 
but  there  may  be  an  inexplicable  aj)athy,  and  in  rare  cases  acute  de- 
lirium. Toward  the  close,  the  increasing  difficulty  in  hsematosis  devel- 
ops carbonic-acid  poisoning,  and  then  stupor  ensues.  The  symptoms 
of  occlusion,  due  to  invagination,  differ  somewhat  from  the  other  forms 
of  obstruction,  and  must  therefore  receive  attention.  The  attack  usu- 
ally sets  in  suddenly  as  the  intussusception  occurs  quickly,  and  the  first 
symptom  is  violent,  colic-like  pain,  which  is  followed  by  vomiting,  the 
more  prompt  and  certain  the  nearer  the  trouble  is  to  the  stomach.  In 
children  the  first  colic-attack  is  followed  after  a  few  hours  by  relief, 
which  continues  for  several  hours  until  a  new  seizure  ;  but  in  the  case 
of  adults  the  pain  which  marks  the  occurrence  of  the  intussusception 
continues  for  several  days,  after  which  it  is  paroxysmal,  there  being 
intervals  of  exemption  from  suffering.  A  very  troublesome  diarrhoea 
is  coincident  with  the  invagination,  from  ten  to  twenty,  or  even  thirty 
discharges  occurring  daily,  and  these  soon  assume  a  dysenteric  charac- 
ter, owing  to  the  intense  congestion  of  the  intestine  at  the  point  of  in- 
vagination. This  symptom  has  greater  significance,  because  no  other 
form  of  occlusion  of  the  bowel  presents  it.  The  tenesmus  is  all  the 
more  severe  when  the  bowel  descends  into  the  rectum,  as  it  sometimes 
does  in  children,  and  with  this  condition  may  be  associated  involun- 
tary discharges  of  mucus  and  blood,  because  of  paresis  of  the  sphincter 
ani.  There  may  be  considerable  variation  in  the  raeteorism  in  invagi- 
nation— great  distention  occurring  immediately  after  the  accident  has 
occurred,  then  subsiding  as  the  diarrhoea  goes  on.     A  cylindrical,  soft, 


OBSTRUCTIOX   OF   THE   INTESTINES.  109 

yet  somewhat  resisting  tumor  can  often  be  detected  on  palpation, 
when  the  invaginations  are  in  certain  places  :  in  the  ciecura,  transverse 
and  descending  colon,  and  at  the  sigmoid  flexure.  It  is  especially  in 
children  and  in  the  chronic  cases  that  these  invagination  tumors  can 
be  detected.  There  are  peculiarities  about  these  tumors  which  should 
be  noted  :  they  change  in  position  somewhat,  and  in  form,  under  the 
influence  of  peristaltic  movements  excited  by  the  necessary  palpation, 
or  occurring  spontaneously.  In  children  the  descent  of  the  ilium  is  so 
very  rapid  that  the  rectum  may  be  reached  on  the  second  day.  An 
intussusception  may  induce  obstruction  at  once,  and  death  occurs  in 
from  three  to  six  days,  partly  by  exhaustion,  partly  by  the  local  in- 
flammation. In  other  eases,  after  the  immediate  closure  of  the  bowel, 
the  canal  is  partly  restored  by  a  subsidence  of  the  local  congestion,  or 
the  obstruction  has  at  no  time  been  complete  :  diarrhoea  of  an  exhaust- 
ing kind  comes  on  ;  gangrene  of  the  invaginated  portion  takes  place  ; 
and  in  children  death  ensues  from  the  fourth  to  the  seventh  day,  but 
in  adults  the  fatal  result  is  postponed  to  the  second,  third,  and  fourth 
week,  according  to  the  acuteness  of  the  symptoms.  When,  in  the  pro- 
cess of  separation  of  the  invaginated  portion  of  the  bowel  already 
described,  the  discharge  of  the  gangrenous  parts  takes  place,  it  does 
not  always  occur  in  its  entirety,  but  shreds  and  masses  of  various  sizes 
are  cast  off,  so  that,  indeed,  the  fact  of  such  sloughs  being  present  in 
the  evacuations  may  escape  detection.  In  the  only  case  of  invagina- 
tion in  which  the  bowel  itself  sloughed  off  in  its  entirety,  in  the  prac- 
tice of  the  author,  the  lost  piece,  a  part  of  the  ilium,  was  eight  inches 
in  length,  entire  as  respects  the  presence  of  all  the  layers  of  the  bowel, 
and  showing  the  evidences  of  gangrene  only  at  the  line  of  separation. 
This  occurred  on  the  eighteenth  day  of  the  disease,  the  patient  recover- 
ing. Again,  cases  of  intussusception  become  chronic,  last  for  months, 
even  for  a  year  or  two,  and  then  recovery  ensues,  or  death  takes 
place  by  gangrene,  by  perforation,  by  peritonitis,  or  by  all  of  these 
accidents  combined. 

Diagnosis. — The  diagnosis  involves  the  two  questions — 1.  Of  the 
form  of  disease  causing  obstruction  ;  2.  Of  the  seat  of  the  obstruction. 

1.  Form  of  Ohstrxiction. — This  is  usually  a  matter  of  inference  ; 
nevertheless,  there  are  considerations  which  may  conduct  the  observer 
to  right  conclusions.  Palpation  and  inspection  of  the  rectum  may  de- 
termine the  existence  of  a  tumor,  an  enterolith,  or  fecal  accumulation. 
Fecal  accumulations  may  also  be  distinguished  by  palpation  at  the 
sigmoid  flexure  and  at  the  ctecum,  and  the  diagnosis  may  be  aided  by 
the  history  of  constipation.  The  occurrence  of  previous  attacks  of 
hepatic  colic,  if  within  a  reasonable  period,  would  be  a  presumption  in 
favor  of  obstruction  caused  directly  by  a  biliary  calculus,  or  of  impac- 
tion, the  calculus  serving  as  a  nucleus  for  the  formation  of  fecal 
masses.     If  attacks  of  typhlitis,  of  pelvic  peritonitis,  or  of  peritonitis 


110  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

in  other  situations  have  occurred  before,  it  may  be  that  a  knuckle  of 
intestine  has  been  fastened  by  such  a  band.  If  a  floating  kidney  or 
other  tumor  has  been  known  to  exist  in  a  situation  to  compress  the 
bowel,  when  sudden  occlusion  occurs,  the  cause  will  be  at  once  sus- 
pected. 

2.  Seat  of  Obstruction. — The  diagnosis  of  the  position  at  which 
obstruction  has  occurred  is  a  little  less  uncertain  than  the  determina- 
tion of  the  form  of  disease. 

The  distention  of  the  abdomen — the  meteorism — may  furnish  val- 
uable diagnostic  indication.  "When  the  colon  at  its  lower  part  is 
obstructed  the  rectum  will  be  empty,  but  the  transverse  and  ascend- 
ing colon  will  form  a  prominent  roll,  the  rest  of  the  abdomen  being 
relatively  sunken.  Ultimately  the  stretching  of  the  large  bowel  will 
render  the  ileo-csecal  orifice  incompetent,  and  then  the  small  intestines 
will  be  inflated  and  the  whole  abdomen  swollen.  When,  as  is  so  fre- 
quently the  case,  the  obstruction  is  at  the  ileo-csecal  valve,  the  whole 
of  the  large  intestine  will  be  empty,  and  then  the  flanks,  and  the  epi- 
gastrium will  be  relatively  flat  and  sunken,  while  the  center  of  the 
abdomen,  all  around  the  umbilicus,  will  be  prominent  and  distended. 
By  palpation  and  percussion  the  situation  of  a  tumor,  or  of  a  fecal 
accumulation,  can  be  made  out. 

When  obstruction  occurs  in  the  jejunum  or  duodenum,  the  course 
downward  into  collapse  is  more  rapid,  the  vomiting  and  hiccough  more 
persistent  and  exhausting  than  when  the  same  obstruction  exists  at 
other  points.  Furthermore,  the  abdomen  is  not  distended,  may  be  re- 
tracted even,  and  the  vomited  matters  contain  no  faeces.  The  urine  is 
scanty  in  obstructions  high  up,  and  plentiful  when  the  obstacle  is  low 
down  in  the  colon. 

If  the  symptoms  have  occurred  suddenly,  and  are  very  acute,  espe- 
cially if  peritonitis  is  present,  a  tight  strangulation  is  probable — behind 
a  band,  in  a  slit  in  the  omentum,  or  beneath  the  attached  appendix.* 
If  acute  symptoms  of  obstruction  have  set  in  after  some  violent  mus- 
cular efforts — as  jumping — the  patient  previously  free  from  disease,  a 
twist  in  a  loop  of  intestine  has  probably  taken  place.  Has  blood  passed 
by  stool  in  a  child  who  has  suffered  from  diarrhoea,  and  the  symptoms 
of  occlusion  have  come  on  suddenly,  intussusception  is  the  most  prob- 
able nature  of  the  accident.  Whenever  symptoms  of  obstruction  occur 
in  a  woman  who  has  borne  many  children,  or  is  the  subject  of  external 
hernia,  or  in  one  who  has  had  attacks  of  peritonitis,  the  existence  of 
strangulation  by  bands  of  adhesion  is  very  probable. f 

Course,  Duration,  and  Termination. — All  of  these  points  have  been 
more  or  less  discussed,  but  some  additional  observations  may  be  neces- 

*  Bryant,  "  The  Medical  Times  and  Gazette,"  vol.  i,  1872,  p.  363.  , 
f  J.  Hutchinson,  ibid.,  vol.  i,  1858,  p.  34. 


OBSTRUCTION   OF  THE   INTESTINES.  HI 

sary.  The  various  occlusions,  even  when  they  have  existed  to  a  partial 
extent  for  a  long  time,  begin  suddenly  and  with  violent  symptoms  ; 
their  course  is  rapid,  and  they  terminate  in  recovery,  in  partial  recovery, 
in  peritonitis,  with  or  without  perforation  or  gangrene.  Peritonitis  is 
a  common  result.  It  is  announced  by  greater  fullness  of  the  abdomen, 
increased  embarrassment  of  breathing,  more  frequent  vomiting  and 
hiccough,  rise  of  temperature,  and  deepening  of  the  collapse.  The 
duration  in  the  average  is,  according  to  Leichtenstern,  six  days  ;  but  a 
child  may  be  killed  by  the  shock  of  an  intussusception  in  a  few  hours. 
They  may  last  two  or  three  weeks. 

Prognosis. — In  every  case  of  occlusion  the  prognosis  is  grave  ;  for, 
although  even  very  unpromising  cases  may  yield  to  treatment,  yet  the 
result  is  so  usually  fatal  that  the  most  guarded  opinions  only  should 
be  given.  The  prognosis  is  more  favorable  in  cases  of  impaction  by 
faeces  than  any  other  form  of  obstruction. 

Treatment. — Until  the  character  of  the  obstruction  is  ascertained, 
no  attempt  should  be  made  to  procure  a  movement  of  the  bowels  by 
active  purgatives  or  by  enemata.  If  impaction  be  ascertained,  the 
treatment  already  described  should  be  put  in  force.  If  intussuscep- 
tion be  the  cause  of  obstruction,  then  certain  kinds  of  enemata  are 
used.  Nevertheless,  the  rule  holds  good  that  in  obstruction  all  violent 
and  perturbing  measures  are  improper.  On  the  other  hand,  the  utmost 
quietude  is  necessary,  in  respect  to  the  movements  of  the  patient  as 
well  as  to  the  use  of  remedies.  Foremost,  and  above  all  measures, 
stands  opium,  administered  with  the  view  to  maintain  a  quiescent  state 
of  the  intestinal  canal,  and  not  less  for  its  influence  over  the  inflam- 
mation and  spasm  which  arise  in  the  course  of  the  various  obstructions. 
The  most  effective  mode  of  administration  is  by  the  hypodermatic 
injection  of  morphia.  The  quantity  is  measured  solely  by  the  effect 
produced.  There  should  be  sufficient  morphia  administered  to  quiet 
the  i^ain,  to  lower  the  pulse,  and  to  maintain  a  state  of  somnolence 
from  which  the  patient  may  be  easily  aroused.  This  is  accomplished 
in  adults  by  one  fourth  of  a  grain  of  morphia  and  y^-o  grain  of  atropia 
for  the  first  injection,  and  by  one  eighth  of  a  grain  subsequently,  and 
every  four  to  six  hours,  according  to  the  degree  of  effect.  With  each 
subsequent  dose  from  the  first,  the  quantity  of  atropia  should  not  be 
greater  than  ^i-g  of  a  grain,  for  the  effect  is  much  longer  maintained 
than  is  the  case  with  morphia.  When  impaction  exists,  the  use  of  the 
opium  would  seem  not  to  be  indicated,  since  constipation  is  a  leading 
factor,  but  even  in  these  cases  the  result  of  its  administration  is  much 
more  favorable  than  the  treatment  by  purgatives,  which  in  vain  are 
used  to  overcome  the  obstacle  ;  while,  if  the  opium  be  persisted  in, 
the  bowels  move  spontaneously.  Purgatives  failing  to  remove  a  fecal 
accumulation,  an  invagination,  or  internal  strangulation,  increase  all 
the  dangers — of  gangrene,   of  perforation,   and  of  peritonitis.     It  is 


112  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

greatly  more  efficient  to  give  opium  in  the  form  of  morphia  subcuta- 
neously,  but  various  preparations  of  the  crude  drug  may  be  adminis- 
tered by  the  stomach  or  by  the  rectum,  the  object  in  view  being  the 
same.  Next  to  the  subcutaneous  method,  probably  the  most  effective 
mode  of  administration  is  by  the  rectum.  For  stomachal  use,  the  best 
preparation  is  the  official  deodorized  tincture. 

If  the  meteorism  be  very  pronounced,  this  increases  the  difficulty  of 
relieving  the  invagination  or  the  internal  strangulation  by  maintaining 
an  over-distention  of  the  intestine  above  the  point  obstructed.  The 
gas  may  be  safely  removed  by  puncture  within  a  fine,  long  needle  of 
the  aspirator.  This  little  operation,  by  removing  an  accumulation  of 
gas,  has  permitted  the  reduction  of  strangulated  hernia,  which  had 
previously  resisted  the  most  skillful  taxis.  Experience  has  abundantly 
shown  that  the  distended  intestines  may  be  punctured  at  various 
points  without  any  ill  result,  immediate  or  remote.*  An  intussuscep- 
tion through  the  ileo-csecal  valve  or  an  imj)action  of  the  csecum  and 
ascending  colon  may  now  and  then  be  overcome  by  hydrostatic 
pressure — by  filling  the  intestine  gradually  with  water  at  95°  from  a 
reservoir  placed  at  a  sufficient  elevation.  Air  or  gas  may  be  used  for 
the  same  purpose.  A  neat  way  to  effect  it  is,  to  disengage  carbonic- 
acid  gas  in  the  rectum  by  injecting  first  a  solution  of  sodium  bicar- 
bonate, and  following  this  with  a  solution  of  tartaric  acid.  About  a 
drachm  of  each  will  be  required.  A  firm  compress  must  be  held  against 
the  anus  with  sufficient  strength  to  prevent  the  escape  of  the  gas. 
Such  is  the  elastic  force  of  the  gas,  that  the  intestine  is  distended,  the 
ileo-csecal  orifice  expanded,  and  the  intruded  bowel  forced  back.  For 
the  success  and  safety  of  this  expedient,  it  is  essential  that  it  be  used 
before  peritoneal  exudation  and  adhesions  have  formed — before,  in- 
deed, the  intruded  bowel  is  much  swollen.  If  put  off  too  long,  adhe- 
sions, to  prevent  rupture  into  the  peritoneal  cavity,  may  be  destroyed, 
or  a  softened  condition  of  the  bowel  will  yield  before  the  pressure  of 
the  gas,  and  a  rent  occur.  For  these  and  other  reasons,  an  experiment 
of  this  kind  should  be  undertaken  early.  The  distention  of  the  bowel 
by  air  forced  in  by  an  ordinary  pump  may  be  used  instead  of  gas,  or 
tobacco-smoke  may  be  injected,  partly  to  act  mechanically,  partly  as  a 
relaxing  agent.  The  infusion  of  tobacco  was  formerly  much  employed, 
but  rarely  now,  as  an  enema  to  relax  the  muscular  fiber  of  the  intes- 
tine. It  is  a  very  dangerous  application,  and  is  not  as  effective  as 
other  means  now  used. 

Warm  applications  to  the  abdomen  afford  comfort,  if  they  do  not 
affect  the  course  of  the  disease.  If  there  be  local  tenderness — in  the 
right  iliac  fossa,  for  example — an  ice-bag  may  be  placed  over  the  pain- 
ful spot,  and,  if  the  temperature  is  elevated,  leeches  may  be  used  cau- 

*  Trousseau,  "  Clinique  Medicalc,"  op.  cit. 


INTESTINAL   PARASITES.  113 

tiously.  Whenever,  in  intestinal  maladies,  leeches  are  to  be  applied, 
the  anal  region  should  be  selected.  As  the  strength  of  the  patient  is 
rapidly  reduced,  much  attention  should  be  paid  to  alimentation.  Solid 
food  should  not  be  given.  Milk,  eggs,  and  meat-juice  are  proper.  If 
vomiting  persists,  lime-water  should  be  added  to  the  milk.  Cham- 
pagne and  cracked  ice  are  highly  grateful  to  the  patient,  and  allay 
vomiting.  Stimulants  are  required  as  the  symptoms  of  collapse  appear. 
Carbolic  acid  in  mint  and  cherry-laurel  waters  is  useful  to  allay  nausea 
and  to  remove  the  fetor  of  stercoraceous  vomiting.  The  author  is 
aware  that  many  practitioners  administer  various  agents  in  combina- 
tion with  opium,  partly  to  increase  its  efficacy,  it  is  supposed,  and 
partly  on  account  of  some  virtue  in  the  remedy.  Calomel  is  most  fre- 
quently so  employed,  and,  as  the  author  believes,  to  the  injuiy  of  the 
patient,  except  when  given  in  very  minute  doses  to  allay  irritability 
of  the  stomach.  The  relief  of  internal  strangulation,  by  surgical  meth- 
ods, does  not  come  within  the  scope  of  a  strictly  medical  treatise.  The 
reader  is  referred  to  papers  by  Mason  and  Ashhurst.* 

INTESTINAL   PARASITES. 

Forms. — Only  those  parasites  having  their  habitat  in  the  intestinal 
canal  will  be  considered.  Trichinosis,  the  most  important  subject  in 
helminthiasis,  pertains  to  the  class  of  general  diseases,  and  will  there- 
fore be  treated  of  in  that  connection. 

But  twenty-one  of  the  large  number  of  parasites  infesting  the 
human  body  are  found  in  the  intestinal  canal,  and  of  these  only  eight 
are  peculiar  to  man.     They  are  as  follows  : 

r  Taenia  solium, 
Cestoda  (Tape- worms) :  <  Taenia  saginata, 

I  Bothriocephalus  latus. 
'Ascaris  lumbricoides, 
Oxyuris  vermicularis, 
Nematoda  (Round  Worms) :  \  Trichocephalus  dispar, 

Trichina  spiralis, 
Anchylostomum  duodenale. 

One  parasite  at  a  time  is  the  rule— two  is  not  an  uncommon  num- 
ber ;  but  Rosen  f  reports  the  case  of  a  child  four  years  of  age  in  whose 
intestines  there  were  ten  lumbricoid  worms,  an  innumerable  quantity 
of  oxyures,  and  four  taeniae.  According  to  Davaine,  J  children  are 
more  affected  by  nematoda  (round  worms),  and  adults  by  cestoda 

*  "  The  American  Journal  of  Medical  Sciences,"  1873  and  1874,  vols.  Ixvi  and  Ixviii. 
f  "  Traite  des  Entozoaires  et  des  mal.  Verm.,"  par  C.  Davaine.     Paris,  1879. 
X  Ibid. 


114  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

(tape- worms),  but  Heller*  maintains  that  adults  are  more  affected  by 
both  classes  of  parasites. 

Origin. — The  doctrine  of  spontaneous  generation  having  received 
its  fatal  blow,  it  is  unnecessary  to  discuss  this  theory  as  applied 
to  intestinal  worms.  It  may  be  regarded  as  settled  that  the  ova  or 
embryos  are  admitted  from  without  and  conveyed  into  the  intestinal 
canal  by  articles  of  food  and  drink.  Hence,  those  who  handle  fresh 
meats  or  eat  uncooked  animal  food  are  specially  liable  to  become  hosts 
of  parasites,  f  Un cleanliness  is  also  an  influential  factor,  and  for  obvi- 
ous reasons. 

General  Results  of  the  Presence  of  Parasites  in  the  Intestinal 
Canal. — There  is  scarcely  a  symptom  which  has  not  been  referred  to 
worms.  Formerly,  as  an  etiological  factor,  worms  had  a  high  degree 
of  importance  ;  but  their  influence  has  been  less  and  less  regarded,  so 
that  now  they  are  almost  wholly  overlooked.  As  is  usual,  doubtless, 
the  truth  lies  between  these  extremes.  The  presence  of  parasites  in 
the  intestinal  canal  is  not  incompatible  with  perfect  health  and  the 
entire  absence  of  symptoms.  The  effects  produced  are  local  and  sys- 
temic. The  local  symptoms  are,  disorders  of  digestion,  abdominal 
pains,  especially  around  the  umbilicus,  and  an  irritation,  usually  an 
itching,  around  the  anus  ;  but  the  chief  symptom  is  the  appearance  of 
the  worm  or  worms.  The  remote  or  systemic  signs  are  very  numer- 
ous :  thirst ;  salivation  ;  a  capricious,  absent,  or  exaggerated  appetite  ; 
emaciation  ;  irregular  action  of  the  heart,  palpitations,  or  intermit- 
tence  of  the  pulse  ;  cough,  dyspnoea,  laryngismus  stridulus  ;  disorders 
of  taste,  hearing,  smell,  vision  ;  convulsions — such  are  the  varied  reflex 
disturbances  produced  by  parasites  in  the  intestinal  canal.  They  are, 
however,  far  from  usual ;  indeed,  they  are  exceptional,  and  not  deter- 
mined by  the  size,  number,  character,  or  position  of  the  worms,  but  on 
some  special  susceptibility  of  the  affected  person. 

CESTODA—T.EINIA— TAPE-WORMS. 

Varieties. — Taenia  solium  is  the  form  most  common  in  this  country, 
taenia  saginata  comes  next,  while  the  bothriocei3halus  latus  is  rare. 

Causes. — The  development  of  taenia  in  its  different  phases  has  now 
been  thoroughly  demonstrated.  Bothriocephalus  latus  has,  however, 
thus  far  eluded  research.  A  tape-worm  reaches  its  final  growth  in  the 
intestinal  canal,  from  an  embryo — an  intermediate  stage  in  its  course 
of  development — admitted  into  the  canal  by  means  of  infested  meat. 
Since  the  introduction  of  the  Russian  method  of  curing  diarrhoea  by 
the  use  of  finely-scraped  raw  meat,  and  the  modern  taste  of  eating 
rare  steaks,  etc.,  tape-worm  has  become  more  common.     Taenia  solium 

*  "  Intestinal  Parasites,"  Ziemssen's  "  Cyelopaedia." 
f  Cobbold,  "Entozoa."     London,  1864,  p.  232. 


INTESTINAL   PARASITES. 


115 


Fig.  S. —  Tcenia  solium,  or  solitary  worm.  a. 
head,  or  scolex ;  b.  tape  formed  of  miiE}'  indi- 
viduals, the  last  of  which,  completely  "sexual, 
separate  under  the  name  of  proglottides,  and 
represent  the  adult  and  complete  animal.  Each 
solitary  worm  is  a  colony. —  Van  Beneden. 


Fig.  T>. — Bothriocephalus  latus.  ff,  scolex;  &,  the 
proglottides;  c,  the  sexual  organs. —  Van  Be- 
neden. 


Fig.  4. — a,  Eostellum ;  &,  crown  of  hooks ;  c.  c, 
suckers ;  1,  scolex  of  the  tsenia  solium  ;  2.  hooks 
expanded ;  a,  heel  of  the  hook. —  Van  Beneden. 


Fig.  6.— Bothriocephalus  latus,  egg.—  Van  Bene- 
den. 


116 


DISEASES   OF   THE   DIGESTIVE   SYSTEM. 


Fig.  7. — Bothriocepha- 
lus  latus,  scolex. 


is  derived  from  the  embryos  contained  in  pork,  known  as  cysticercus 
cellulosics,  and  T.  saginata,  from  embryos  found  in  beef.  The  bothri- 
ocephalus  is  supposed  to  be  derived  from  an  embryo  found  in  fish, 
but  not  correctly  so,  as  it  occurs  among  peoples  liv- 
ing on  the  seashore  and  at  the  borders  of  lakes,  and 
in  the  interior  of  continents  as  well. 

Symptoms  and  Results. — The  small  intestine  is 
the  abode  of  taenia,  but  when  very  long  it  may 
reach  into  the  large  intestine.  The  head  is  fixed 
against  the  mucous  membrane  just  below  the  pylo- 
rus. The  T.  solium  is  usually  solitary,  but  not  al- 
ways, and  a  number  of  them  may  be  found  in  one 
host.  The  immense  length  of  the  segments  dis- 
charged often  gives  rise  to  the  impression  that  there 
must  be  several  of  them  to  produce  such  a  quan- 
tity. Although  more  frequent  in  adults,  no  age  is 
exempt,  and  infants  at  the  breast  have  been  in- 
fested after  feeding  on  raw  beef -pulp.  Dr.  Armor  * 
reports  a  case  of  taenia  in  an  infant  five  days  old. 
Women  are  more  subject  than  men  to  taenia  :  in 
one  hundred  and  sixty-four  cases,  ninety  belonged  to  women  and 
seventy-four  to  males.  Segments  or  strobila  of  the  tape-worm  colony 
pass  in  numbers  spontaneously,  and  after  the  action  of  medicines  ;  and 
now  and  then  the  living  proglottides  migrate,  crawl  out  of  the  anus,  and 
are  felt,  cool  and  moist,  wriggling  about  the  hips,  thighs,  and  genitals. 
Very  rarely,  portions  of  a  tape-worm  are  thrown  up  by  vomiting.  The 
length  of  time  they  remain  in  the  intestine  is  by  no  means  a  fixed 
period  ;  they  have  been  known  to  exist  there  ten  to  twelve  years, 
and  even  longer  ;  but  there  are  very  obvious  difficulties  in  the  way  of 
accurate  determination  of  this  point. 

The  presence  of  a  tape-worm  when  recognized  by  the  patient  induces 
serious  inquietude  of  mind,  but  not  necessarily  any  disturbance  of  the 
bodily  functions.  Not  unfrequently,  a  tape-worm  produces,  absolutely, 
no  symptoms.  The  degree  of  disturbance  caused  is  determined  by  the 
characteristics  of  the  affected  person — they  who  suffer  much  are  ner- 
vous and  easily  susceptible  to  impressions  of  all  kinds.  In  a  large 
proportion  of  cases,  the  presence  of  the  proglottides  in  the  evacuations 
is  the  first  intimation  of  the  presence  of  the  worm  in  the  intestinal 
canal.  The  principal  symptoms  are  :  emaciation,  notwithstanding  an 
inordinate  appetitite  ;  a  feeling  of  lassitude  ;  colicky  pains  felt  through 
the  abdomen  ;  palpitation  of  the  heart,  faintness  ;  salivation  ;  disor- 
dered digestion  ;  pruritus  of  the  anus  and  nose  ;  disorders  of  the  special 
senses,  notably  feebleness,  etc.     Sometimes  the  disagreeable  feelings  in 


*  "New  York  Medical  Journal,"  December,  1871. 


EsTESTIXAL   PAEASITES.  117 

the  abdomen  are  removed  by  taking  food.  Probably  the  most  constant 
symptom  is  the  colicky  pains  felt  in  different  parts  of  the  abdomen  ; 
but  they  are  not  always  present,  are  intermittent,  and  vary  as  much  in 
severity  as  in  situation.  Constipation  is  more  usual  than  diarrhoea, 
and  they  may  alternate.  Itching  about  the  anus  and  nose  is  a  common 
symptom,  and  is  rarely  absent  from  one  or  the  other  situation,  but 
itching  of  the  anus  is  more  frequent.  The  nervous  phenomena,  strictly 
speaking,  are  very  pronounced,  consisting  of  affections  of  the  special 
senses,  i^ains  and  cramps  in  the  extremities,  choreic  seizures,  epilep- 
tiform attacks,  hysteria,  etc.  In  a  few  cases  the  patients  experienced 
a  horrible  odor,  jDirrely  subjective  ;  others  have  disagreeable  sensations 
excited  by  music  ;  others  have  impaired  vision,  sometimes  complete 
amaurosis,  now  affecting  one  eye,  now  the  other  ;  again,  there  are 
those  who  have,  instead  of  itching,  a  sensation  of  hypersesthesia  or 
anaesthesia  in  certain  parts  of  the  body,  a  m.omentary  loss  of  voice  or 
of  memory,  persistent  wakefulness,  epistaxis,  etc.  The  most  important 
symptom  is  the  passage  of  strobila,  or,  more  frequently,  proglottides. 
Each  proglottis  contains  the  sexual  apparatus  complete  and  a  multitude 
of  embryos,  and  has  a  power  of  motion  when  first  detached  from  the 
strobila  or  tape-worm  colony.  It  is  then  a  segment — a  moist,  whitish, 
cool,  quadrangular  body,  like  a  bit  of  stout  white  tape,  but  changing 
its  shape  constantly  so  long  as  the  power  of  motion  lasts.  Inspected 
with  an  ordinary  pocket  lens,  the  uterus  and  ovisacs,  with  their  lateral 
branches  on  one  side,  and  the  testicular  bodies  on  the  other  side,  can 
readily  be  seen.  It  is  quite  possible  to  differentiate  between  the  T. 
solium  and  T.  saginata  by  an  inspection  of  the  proglottides  —  the 
former  being  thinner,  softer,  and  more  transparent.  The  lateral 
branches  of  the  uterus  of  the  T.  solium  are  from  nine  to  twelve  in 
number,  and  of  the  T.  saginata  fifteen  to  twenty,  and  the  latter  are 
much  smaller. 

Treatment. — There  are  two  separate  stages  in  the  process  of  expul- 
sion of  the  parasite — the  preparatory  treatment ;  the  exhibition  of  the 
tseniafuge.  The  preparation  of  the  patient  consists  in  the  use  of  a 
laxative  to  remove  mucus  and  other  matters  in  which  the  scolex,  or  head, 
is  imbedded,  and  to  prevent  accumulation  of  such  matters  by  a  low 
diet,  which  will  leave  almost  no  residuum.  Sulphate  of  magnesia 
should  be  administered  each  morning  for  two  mornings  before  giving 
the  remedy — one  or  two  teaspoonfuls  at  a  time  in  sufficient  water. 
The  diet  should  consist  of  milk,  steak,  tea,  and  toast,  for  the  day 
before  and  during  the  treatment.  German  practitioners  cause  the 
patient  to  take  certain  articles  which  experience  has  shown  are  highly 
disagreeable  to  the  parasite — such  as  garlic,  onions,  and  salt-herring 
— and  accordingly  they  direct  a  plateful  of  herring-salad,  a  savory 
dish  made  up  of  those  articles,  agreeable  enough  to  Germans,  but 
highly  distasteful  to  tape-worms  !    The  medicine  need  not  be  given  on 


118  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

an  empty  stomach  ;  the  patient  may  take  a  cup  of  coffee  before  begin- 
ning the  medicine.  Many  remedies  have  been  proposed,  and  opinions 
are  diverse  as  to  their  utility.  Heller  prefers  kousso  ;  Cobbold,*  ex- 
tract of  male  fern  ;  while  Davaine  does  not  indicate  his  preference  ;  and 
Kuchenmeister,f  after  an  exhaustive  examination  of  the  almost  innu- 
merable methods,  ancient  and  modern,  declares  his  preference  for  the 
decoction  of  pomegranate.  The  author's  experience,  which  has  been 
not  inconsiderable,  is  decidedly  in  favor  of  the  pomegranate.  The 
most  successful  treatment  of  tape- worm  the  author  has  any  knowledge 
of,  is  that  of  an  ignorant  barber,  who  has  a  secret  method  which  seems 
never  to  fail.  He  does  not  attempt  any  preparatory  treatment,  but 
administers  his  medicine  (apparently,  a  decoction  of  pomegranate)  in 
the  morning,  the  patient  fasting,  and  retires  from  the  house  with  the 
worm  and  his  fee  at  noon. 

Kiichenmeister  prepares  his  decoction  of  pomegranate  as  follows  : 

5  iij  of  fresh  bark,  after  macerating  for  twelve  hours  in  3  xij  of  water, 
are  concentrated  to  3  vj  by  a  gentle  heat,  and  this  fluid  is  taken  in 
three  doses  within  an  hour.  He  precedes  the  administration  of  the 
pomegranate  by  one  day  of  fasting,  and  2  ij  of  castor-oil,  taken  the 
night  before.  He  prefers  to  add  to  the  pomegranate  the  ethereal  ex- 
tract of  filix  mas  and  extract  of  tansy,  3j  —  3  ss  of  the  former  and 

3  ij  of  the  latter.  J 

Heller  administers  the  kousso  in  a  sjDecial  manner — by  the  method 
of  Rosenthal — which  consists  of  compressed  balls  or  disks  coated  with 
gelatine.  Five  drachms  is  the  quantity  required  for  a  T.  solium,  and 
seven  and  a  half  drachms  for  a  T.  saginata.  The  gelatine-coated 
balls  and  disks  are  placed  as  far  back  on  the  tongue  as  possible 
and  swallowed  alone,  or  aided  by  some  coffee.  The  tendency  to 
vomit  must  be  resisted — mustard  applied  to  the  epigastrium,  small 
bits  of  ice  swallowed,  the  recumbent  posture  maintained.  Two  hours 
after  the  last  bolus,  an  ounce  or  two  of  castor-oil  should  be  admin- 
istered, the  object  being  to  expel  the  worm  speedily  and  entire. 
Heller  aflirms  that  this  method  is  highly  successful,  but  Kiichen- 
meister thinks  kousso  an  uncertain  remedy.  The  author's  experience 
with  it  has  been  unfavorable — it  expelled  a  large  quantity  of  the 
worm,  the  strobila,  but  not  the  head  or  scolex  ;  but  it  was  adminis- 

*  "  Entozoa,"  op.  cit.,  p.  233. 

f  "On  Animal  and  Vegetable  Parasites  of  the  Human  Body."  By  Dr.  Frederick 
Kiichenmeister.     Sydenham  Society  edition,  vol.  i,  p.  171. 

jj.  The  active  principle  of  pomegranate — pclleterine — ^may  hereafter  be  preferred.  In 
a  communication  to  the  "Bull.  Gen.  de  Therap.,"  July  15,  1879,  Dr. Berenger  Ferand  re- 
ports comparative  trials  with  the  tannate  and  sulphate  of  pelleterine,  prepared  by  M.  Ch. 
Tanret,  the  discoverer.  lie  finds  the  tannate  more  efficient.  The  dose  is  forty  to  fifty 
centigrammes,  administered  fasting,  the  diet  the  previous  day  consisting  of  milk  and 
bread.  The  remedy  is  followed  by  compound  tincture  of  jalap,  or  castor-oil,  or  sul- 
phate of  soda. 


INTESTINAL   PARASITES.  119 

tered  in  a  decoction,  the  patient  swallowing  a  great  mass  of  leaves, 
stems,  and  flowers,  so  that  vomiting  could  hardly  be  resisted.*  The 
method  by  fern  consists  in  the  administration  of  the  so-called  ethereal 
extract — the  oleoresin — in  3  ss  doses,  fasting.  It  is  most  pleasantly 
taken  in  perles  or  capsules.  If  of  good  quality,  and  given  after  suit- 
able preparation  in  an  efficient  dose,  it  is  a  successful  remedy — ac- 
cording to  Cobbold,  the  best  of  the  group  of  taeniafuges.  The  seeds 
of  the  common  field  pumpkin  is  a  homely  but  very  efficient  rem- 
edy, which  deserves  to  rank  among  the  best  of  the  class.  The  fresh 
seeds  are  rubbed  up  into  an  emulsion  by  the  addition  of  some  water^ 
the  woody  liber  separated  by  a  coarse  sieve,  and  the  mixture  drunk 
fasting.  Usually  no  purgative  is  required,  but  one  should  be  given 
if  the  bowels  do  not  act  promptly.  The  failures  are  due,  simply,  to 
the  difficulty  of  retaining  a  sufficient  quantity.  A  great  many  cures 
have  been  effected  by  tui-pentine  ;  it  is,  indeed,  one  of  the  most 
efficient  of  tseniafuges,  but  the  natural  repugnance  to  swallowing  such 
a  dose,  the  powerful  effects  produced  by  it,  and  the  subsequent  ill 
resitlts,  are  such  as  to  hinder  its  emj)loyment,  and  to  restrict  it  to 
the  cases  which  have  resisted  other  means.  Large  doses,  acting 
promj)tly  as  a  cathartic,  are  not  so  injurious  as  the  smaller  doses 
which  pass  off  by  the  kidneys.  From  one  to  two  ounces  of  turpen- 
tine, and  as  much  castor-oil,  are  administered  together.  Kameela — 
"the  glandular  powder  and  hairs  from  the  capsules  of  rottlera  tinc- 
toria  " — is  an  efficient  remedy,  without  being  very  unpleasant.  The 
dose  is  3  j  —  3  iij,  repeated  every  three  hours,  if  necessary.  No  pur- 
gative is  required.  The  stools  should  be  carefully  and  minutely  in- 
spected, for  the  medicine  is  not  successful  if  the  scolex  is  not  expelled. 
The  head  with  its  row  of  booklets,  its  suckers,  etc.,  can  be  recognized 
by  the  naked  eye,  but  an  ordinary  pocket  lens  will  bring  out  all  parts 
with  sufficient  distinctness  to  render  an  inspection  positive.  If  the 
scolex  is  not  found,  and  is  retained,  in  six  weeks  to  three  months  the 
segments  or  proglottides  will  be  passing  again. 

JBothriocephahis  latus  is  usually  classed  with  tape-worms,  and  clini- 
cally properly  so,  but,  zoologically  considered,  it  is  not  a  tape-worm. 
Its  habitat  is  the  small  intestine — its  scolex  attached  to  the  mucous 
membrane  of  the  duodenum  by  its  suckers.  It  is  found  more  fre- 
quently in  the  adult  and  in  the  female.  Its  size  is  greater  than  that 
of  taenia  ;  its  segments  are  not  detached  at  maturity,  and  do  not  main- 
tain an  independent  life.  Detached  parts  of  considerable  extent  are 
expelled  at  long  intervals.  It  is  ordinarily,  but  not  invariably,  soli- 
tary. According  to  Odier,  who  has  observed  many  cases  at  Geneva, 
the   bothriocephalus  causes  swellings  of  different  parts  of  the  abdo- 

*  An  alcoholic  extract,  under  the  name  of  koossin,  is  now  used  instead  of  the  crude 
drug,  and  it  is  alleged  (Heller)  with  few  failures,  but  the  same  success  has  not  attended 
it  elsewhere.     The  dose  is  thirty  grains. 


120 


DISEASES   OF   THE   DIGESTIVE   SYSTEM. 


men,  irregular  stools,  nausea,  vertigo,  palpitations,  night  terrors,  etc. 
There  may  be  no  symptoms  at  all.  When  symptoms  do  occur,  they 
are  about  the  same  as  those  already  described  for  taenia.  The  expul- 
sion of  the  bothriocephalus  is  accomplished  more  readily  than  is  the 
tape-worm.  Kousso  rarely  fails.  The  oleoresin  of  filix  mas  is  also 
successful.  Kameela  has  been  found  efficient.  In  fact,  any  of  the 
remedies  already  referred  to  as  taeniafuges  may  be  used  against  this 
worm.  In  Switzerland,  the  secret  remedy  of  Peschier,  supposed  to  be 
fern,  is  much  used. 


NEMATODA— ASOARIS   LUMBRICOIDES— ROUND   WORMS. 

General  Considerations. — The  lumbrici  are  found  under  all  con- 
ditions of  climate — in  cold,  in  warm,  in  moist,  and  in  dry  climates. 
They  sometimes  appear  so  generally  as  to  become  epidemic.  In  cer- 
tain epidemics  of  dysentery,  Avorms  in  large  numbers  appeared  in  the 
evacuations.     But  these  observations,  made  in  the  last  century,*  are 

open  to  suspicion,  for  in  those  times 
the  pathological  importance  of  worms 
was  much  greater  than  now.  It  is 
true,  even  now,  under  certain  local 
conditions,  that  worms  are  very  com- 
mon— so  much  so  as  to  constitute  an 
epidemic,  and,  in  some  epidemics  of 
fever  and  of  dysentery,  great  numbers 
of  worms  appear  in  the  intestinal  tracts. 
The  great  mode  of  propagation  is  by 
drinking-water.  The  ova  of  the  round 
worm  resist  freezing  and  a  very  high 
temperature,  and  are  surrounded  by 
such  a  strong  envelope  as  to  oppose 
successfully  ordinary  destructive  influ- 
ences, and  live  for  years.  It  follows 
that,  in  country  places,  where  human 
excreta  easily  gain  access  to  drinking- 
water,  numbers  of  people  may  be  simul- 
taneously affected,  or  in  quick  succes- 
sion. Filthy  habits  of  a  jDeoiDle — of  a 
community  of  negroes,  for  example — 
contribute  greatly  to  the  propagation  of  lumbrici,  by  the  dissemination 
of  ova  through  articles  of  food  and  drink. 

The  number  of  ascarides  existing  at  one  time  in  the  intestinal  canal 
is  various  :  there  may  be  one,  two,  or  three  worms,  or  they  may  reach 


Fig.  8.— a  scans  lumbriooides  — 1,  complete 
worm  ;  2,  head  ;  3,  tail  of  the  male  ;  4, 
middle  of  the  body  of  female. 


Davaine,  op.  ciL 


DsTESTIXAL  PARASITES.  121 

five  hundred  or  thousands.  "When  very  numerous,  they  may  be  grouped 
in  rolls  or  bundles,  distending  the  whole  or  a  part  of  the  intestine,  or 
occluding  it.  Their  place  of  sojourn  is  in  the  small  intestine.  They 
occur  in  early  life  chiefly,  although  Heller  asserts  the  contrary,  and 
are  not  common  under  one  year  and  after  twenty.  Females  are  more 
subject  to  them  than  males,  and  feeble,  lymphatic,  and  strumous  per- 
sons more  than  the  robust.  Poor  aliment,  a  vegetable  diet,  and  fer- 
mented drinks  favor  their  development.  Autumn  is  the  season  of  their 
greatest  prevalence.  From  their  origin  to  the  end  of  their  existence 
rarely  does  more  than  a  year  transpire,  but  our  knowledge  on  this  point 
is  not  very  definite. 

Development. — The  lumbricoid  worm  (Fig.  8)  is  cylindrical  in  shape, 
reddish-brown  or  brownish-yellow  in  color,  and  tapers  at  both  extremi- 
ties ;  but  the  cephalic  extremity  is  larger,  and  contains  at  its  summit 
three  lips  or  papillae,  having  the  mouth  between  them.  The  male  is 
smaller  than  the  female,  and  is  distinguished  by  the  tail  being  always 
turned  toward  the  abdomen  like  a  hook.  The  ova,  which  exist  in 
almost  incredible  numbers,  are  oval  in  shape,  have  an  extremely  tough, 
double  shell,  and  dark,  granular  contents.  The  eggs  when  expelled 
are  slow  to  develop,  several  months,  sometimes  years,  being  required. 
"  They  do  not  lose  their  jjower  of  development  for  several  years,  and 
the  young  embryo,  while  in  the  shell,  also  retains  its  vitality  for  years." 
The  subsequent  steps  in  the  development  of  lumbrici  are  at  present 
quite  iinknown. 

Symptoms. — When  few  in  number,  as  is  the  rule,  the  host  being  in 
good  health,  there  are  no  symptoms  of  any  kind  produced  by  them. 
'  "WTien  very  numerous,  disorders  of  digestion,  of  nutrition,  and  of  the 
nervous  system,  are  caused ;  but  these  results  are  not  iseculiar  to  the 
round  worm,  and  have  been  alluded  to  in  connection  with  the  tape- 
worm. The  usual  symptoms  are  colicky  pains  about  the  umbilicus  ; 
tumefaction  of  the  abdomen  ;  capricious  appetite,  now  insatiable,  now 
wanting  ;  occasional  nausea  and  vomiting  ;  sometimes  diarrhoea  and 
stools  containing  mucus  mixed  with  blood  ;  whey-like  urine  ;  itching 
of  the  nose  and  anus  ;  bluish  coloration  of  the  lower  eyelid,  dilatation 
and  sometimes  inequality  of  the  pupils  ;  emaciation  ;  irregularity  of 
the  pulse  ;  choreic  and  hysterical  seizures  ;  restless  nights,  terrors,  and 
grinding  of  the  teeth  in  sleep,  etc.  Xo  confidence  can  be  placed  on 
the  diagnosis  of  woi-ms  when  all  of  the  foregoing  symptoms  are  present, 
for  they  are  much  more  frequently  produced  by  other  causes.  Hence, 
the  diagnosis  must  be  largely  conjectural  unless  worms  are  passed  from 
time  to  time.  One  or  more  may  be  found  in  the  stools,  and  not  rarely 
worms  are  brought  up  from  the  stomach,  and  excite  gagging  and  stran- 
gling until  disengaged  from  the  fauces.  If  the  symptoms  above  men- 
tioned persist  after  the  ocular  demonstration  of  the  presence  of  worms, 
they  are  probably  due  to  this  cause.     Chorea  and  epileptiform  attacks. 


122  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

in  girls  of  eight  to  fifteen,  may  be  due  to  the  presence  of  worms,  and 
cease  on  their  removal — of  which  numerous  examples  have  fallen  under 
the  author's  observation.  Occasionally  obstruction  of  the  intestine 
has  been  caused  by  a  bundle  of  worms — either  within  the  abdomen,  or 
in  a  herniary  protrusion.  Requin  narrates  a  case,  the  obstruction  oc- 
curring at  two  points — in  the  small  intestine  ;  at  the  middle  of  the 
transverse  colon. 

Ascarides  crawl  up  into  the  pharynx,  the  Eustachian  tube,  the 
nares,  and  the  larynx.  Aronssohn  has  collected  several  cases,  Da- 
vaine  others,  of  death  happening  suddenly  with  symptoms  of  suffoca- 
tion due  to  worms  crawling  into  the  larynx.  Thirty-seven  cases  are 
reported  (Davaine)  of  lumbrici  in  the  biliary  passages,  in  the  substance 
of  the  liver,  or  in  the  cavity  from  rupture  of  the  duct.  The  most  usual 
position  for  them  is  the  common  duct,  which  they  obstruct,  jaundice 
results,  and  ultimately  serious  derangement  of  the  liver  ensues.  He- 
patic abscess  is  also  a  result,  but,  very  rarely,  of  the  lodgment  of  a 
worm  which  has  passed  up  into  the  body  of  the  liver,  and  excited  sup- 
purative inflammation.  In  some  rare  cases  a  worm  has  been  discharged 
by  an  hepatic  abscess  opening  externally.  Worms  have  also  been  dis- 
charged externally  by  fecal  abscesses,  and  they  not  unfrequently  pass 
into  the  cavity  of  the  peritoneum  through  perforations  of  the  intes- 
tines. The  old  notion,  that  round  worms  could  make  their  way  through 
the  uninjured  intestine,  is  now  entirely  exploded. 

Treatment. — There  are  various  remedies  highly  effective  in  the  re- 
moval of  the  ascaris  lumbricoides.  The  most  generally  used  is  santo- 
nine,  or  santonic  acid,  the  active  constituent  of  artemisia  santonica. 
The  advantage  of  this,  besides  its  efficiency,  is  the  slight  taste  and  ease 
of  administration.  It  should  always  be  explained  that  the  vision  of 
those  taking  santonine  is  affected  :  all  objects  seem  as  if  looked  at 
through  yellow-colored  glasses,  and  also  that  the  urine  is  stained  a 
deep  yellow.  In  overdoses  santonine  causes  violent  nervous  symptoms. 
It  is  given  in  the  form  of  powder,  rubbed  up  with  sugar,  or  some  ex- 
tract of  liquorice — two  to  four  grains  at  night,  followed  by  a  laxative 
in  the  morning.  Calomel  has  considerable  vermifuge  property,  and  is 
often  alone  sufficient,  but  is  now  used  as  an  adjunct  to  santonine,  two 
to  four  grains  given  with  the  same  quantity  of  santonine.  This  plan, 
which  is  very  satisfactory,  is  still  more  efficient  if  the  use  of  the  ver- 
mifuge is  preceded  by  hydrocyanic  acid  (the  officinal  dilution),  two  or 
three  drops,  three  times  a  day,  for  two  days.  Next  to  santonine  in 
point  of  efficiency  is  chenopodium  or  worm-seed,  which  is  usually  ad- 
ministered in  the  form  of  the  oil.  Its  powerful  odor  and  disagreeable 
taste  are  strong  objections.  Five  to  ten  drops  can  be  given  in  an 
ounce  of  castor-oil,  or  in  the  fluid  extract  of  spigelia,  also  an  efficient 
vermifuge.  The  fluid  extract  of  spigelia  (pink-root)  may  be  giv6n 
alone  in  from  one  to  four  drachms  at  a  dose,  or  in  the  officinal  combi- 


Es'TESTIXAL   PARASITES. 


123 


nation,  the  fluid  extract  of  senna  and.  spigelia.     Any  of  the  remedies 
named  are  efticient  ao-ainst  the  round  worm. 


OXYURUS   VERMICUIiARIS.— THREAD-WORM. 

Description. — This  parasite  (Fig.  10)  derives  its  common  name — 
thread- worm — from  its  whitish  apearance  and  size — like  a  bit  of  fine 
sewing-cotton.     There  are  two  sexes,  male  and  female,  the  male  being 


Fig.  9.— Trichocephalus  of  Man.— 1,  female:  a,  ce-        Fig.  10.— Oxyurns  Vermicnlaris.— 1.  male  ofnatu- 
phalic  extremity :  6.  caudal  extremity  and  anus;  ral  size  ;  2,  female,  ib. ;  3,  cephalic  extremity, 

c,  d.  dia  estive  tube  and  orary ;  f,  ori.*ice  of  sex-  magnified, 

ual  apparatus.    2.  isolated  egg.    3,  male  :  a.  ce- 
phalic extremity;  5.  anus:  c.  digestive  tube :  d, 

spicula  or  penis" ;  e,  sheath  into  which  it  is  with-  • 

drawn. 

only  one  half  the  size  of  the  female.  The  female  worm  is  scarcely  a 
half  inch  (nine  to  twelve  mm.),  and  the  male  is  about  one  fourth  of  an 
inch  (three  to  five  mm.)  in  length,  cylindrical,  tapering  to  both  ex- 
tremities, but  the  cephalic  end  is  blunter.  The  ova  are  contained  in  a 
stout  envelope  which  resists  considerable  heat  as  w^ell  as  cold,  but  soft- 
ens in  the  intestinal  canal  of  man,  and  discharges  its  embryo,  which 
indeed  may  be  discerned  in  the  mature  eggs,  already  in  process  of  de- 
velopment. The  habitat  of  the  oxyurus  is  the  large  intestine  of  man, 
especially  the  rectum,  and  they  insinuate  themselves  into  the  folds  of  the 
mucous  membrane  and  skin  at  the  margin  of  the  anus.  They  are  most 
abundant  in  early  life,  and  sometimes  at  the  other  extreme,  in  old  age. 
Symptoms. — They  excite  by  their  presence  in  the  rectum  an  intoler- 
able itching,  sometimes  severe  pain,  tenesmus  usually,  and  these  sensa- 
tions are  propagated  to  the  genito-urinary  organs.  The  tormenting 
itching  occurs  at  special  times,  and  is  very  aggravating  at  night,  when 
warm  in  bed.  The  stools  are  usually  a  little  relaxed,  fetid,  and  coated 
with  mucus,  and  occasionally  streaked  with  blood.     An  inspection  of 


124  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

the  parts  discloses  a  reddened  and  roughened  integument  all  about 
the  anus,  and  excoriations  of  the  mucous  membrane  caused  by  the 
repeated  friction  of  the  parts.  The  worms  may  often  be  seen  in  situ, 
or  in  the  evacuations,  but  it  is  necessary  sometimes  to  administer  an 
injection  or  a  laxative  to  procure  ocular  evidences  of  the  presence 
of  these  parasites.  Besides  the  local,  various  reflex  phenomena  are 
induced  by  the  irritation  of  the  oxyurus,  as  epilepsy,  chorea,  cata- 
lepsy, etc.  Unquestionably,  excitation  of  the  sexual  organs  is  thus 
caused,  leading  to  onanism.  Besides  the  reflex,  direct  irritation  of  the 
genitals  in  girls  is  set  up  by  the  presence  of  these  worms  in  the  vagi- 
na, where  they  deposit  their  ova  and  develop  in  immense  numbers. 
Violent  local  inflammation  and  a  blenorrhagic  discharge  are  also  in- 
duced in  this  way,  exciting  suspicion  of  gonorrhoeal  infection.  The 
oxyurus  is  not  confined  to  the  rectum,  nor  are  its  excursions  limited 
to  the  perineum  and  vagina.  It  migrates  upward  into  the  large  intes- 
tine, and  develops  in  the  csecum  ;  but  the  lower  part  of  the  ilium  is 
also  invaded.  So  that,  although  the  proper  habitat  of  the  parasite  is 
the  rectum,  it  should  not  be  overlooked  that  they  exist  in  the  caecum 
and  in  the  lower  part  of  the  ilium  in  great  numbers. 

Treatment. — The  fact  just  stated  in  regard  to  the  jDOsition  of  these 
parasites  in  the  intestinal  canal  is  of  great  importance  in  the  treat- 
ment. The  administration  of  one  of  the  vermifuges,  especially  san- 
tonine,  aided  by  calomel,  should  be  the  first  step  in  the  treatment. 
As  soon  as  this  has  acted,  the  bowel  should  be  irrigated  by  a  weak 
decoction  of  quassia  or  of  aloes.  A  simple  injection  will  usually 
suffice,  since  the  santonine  has  probably  displaced  all  of  the  parasites 
above.  The  decoction  should  also  be  used  as  a  vaginal  injection, 
employing  a  very  small  tube,  so  that  all  of  the  canal  can  be  reached. 
As  the  ova  are  deposited  in  the  folds  of  the  anus,  and  are  not  reached 
by  the  injections,  the  next  step  consists  in  carefully  sponging  out  all 
the  folds  and  crevices  of  the  anus  and  perineum,  and  the  external 
genitals  also,  with  a  one  per  cent,  solution  of  carbolic  acid.  If  treated 
in  this  thorough  manner,  the  applications  being  repeated  a  few  times, 
the  parasites  will  be  entirely  destroyed,  but  neglect  of  any  of  these 
precautions  will  render  repeated  applications  necessary.  Solutions  of 
carbolic  acid  as  an  injection  have  been  used  with  success  in  the  treat- 
ment of  the  oxyurus,  but  such  serious  symptoms  have  ai-isen  in  some 
cases  that  this  practice  ought  not  to  be  continued. 

Tricliocephalus  (Fig.  9)  is  rarely  encountered.  In  respect  to  clini- 
cal history  and  symptoms,  it  does  not  differ  from  the  round  worm. 


PERITONITIS.  125 


DISEASES   OF  THE   PERITONEUM. 


PERITONITIS.— INFLAMMATION   OF   THE   PERITONEUM. 

Definition. — Inflammation  of  the  peritoneum  occurs  in  two  forms — 
acute  and  chronic.  It  may  be  limited  to  a  part,  or  involve  the  whole 
of  the  membrane  :  in  the  former  it  is  local,  in  the  latter  general  peri- 
tonitis. It  may  be  an  independent  affection,  ox  lyrimary,  or  it  may  be 
caused  by  the  extension  of  a  morbid  process,  from  adjacent  organs  or 
tissues,  or  secondary. 

Causes. — As  a  primary  disease  peritonitis  is  rare,  but  it  may  occur 
at  any  age,  even  during  intra-uterine  life.  Intense  cold,  severe  and 
protracted  counter-irritation  by  blisters,  and  blows  on  the  abdomen, 
may  excite  the  inflammatory  process.  Very  much  the  most  frequent 
cause  is  the  extension  of  internal  lesions  of  the  abdomen — e.  g.,  per- 
forations of  the  stomach,  intestines,  bladder,  etc.,  or  inflammation  of 
these  organs.  To  this  category  may  be  added  the  causes  of  pelvic 
inflammation  of  the  uterus  and  annexed  organs.  It  is  not  unfrequently 
an  intercurrent  malady  coming  on  in  the  course  of  certain  cachexite, 
as  pyaemia,  albuminuria,  and  the  eruptive  fevers. 

Pathological  Anatomy. — The  first  step  in  the  inflammatory  process 
is  the  occurrence  of  hypersemia,  the  capillaries  being  enlarged  and  dis- 
tended, and  the  blood-pressure  is  so  increased  within  the  area  of  in- 
flammation that  extravasations  of  blood  occur  at  various  points.  An 
arrest  of  the  normal  secretion  and  an  abnormal  dryness  are  then  evi- 
dent ;  next  an  exudation,  very  thin  but  adhesive,  forms  on  the  in- 
flamed surface  and  glues  the  neighboring  parts  together,  but  not 
firmly,  for  they  may  be  easily  separated.  Simultaneously,  a  reddish, 
serous  fluid  is  poured  out  into  the  cavity.  Th^  inflammation  will  now 
assume  one  of  two  directions — it  will  take  the  adhesive  or  exxcdative 
form.  The  fibrinous  exudation  already  mentioned  is  almost  pure 
fibrin  and  contains  but  few  cellular  elements.  Presently,  however, 
the  cells  of  the  endothelium  become  swollen,  their  contents  granular, 
and  their  nuclei  undergo  multiplication.  If,  now,  the  process  ends 
with  the  adhesive  inflammation,  the  proliferation  of  the  endothelium 
will  soon  be  arrested,  a  delicate  connective  tissue  will  be  formed  from 
the  new  cellular  elements,  blood-vessels  soon  appear,  and  a  distinct 
neo-membrane  is  the  result,  binding  neighboring  surfaces  together,  or 
forming  bands  of  adhesion  of  greater  or  less  extent.  If  the  inflam- 
matory process  assumes  the  other  direction,  the  effusion  increases.  It 
is  at  first  sero-fibrinous,  i.  e.,  a  serous  fluid,  having  masses  of  flocculi 
of  lymph  floating  in  it.  The  deposit  of  fibrin,  which  in  the  other  form 
(adhesive)  is  slight  in  extent,  and  which  disappears  in  the  process  of 


126  DISEASES   OF  THE  PERITONEUM. 

formation  of  the  neo-membrane  from  the  new  cells,  in  this  form  (exu- 
dative) is  very  much  increased,  and  constitutes  a  coating  of  consider- 
able thickness.  The  endothelium  undergoes  extensive  proliferation  ; 
the  connective-tissue  corpuscles  of  the  basement  membrane  also,  and 
new  vessels  develop.  On  separation  of  the  fibrin  layer  from  the  serous 
membrane,  the  latter  bleeds  from  rupture  of  minute  new-formed  ves- 
sels ;  it  appears  dense,  thick,  and  cedematous.  The  swelling,  hypere- 
mia, and  oedema,  also  extend  to  the  sub-peritoneal  connective  tissue, 
and  ultimately  to  the  muscular  tissue,  which  in  turn  becomes  softened, 
pale,  and  flabby.  When  the  inflammation  occurs  in  the  peritoneal  layer 
of  the  liver  or  spleen,  the  tissue  adjacent  to  the  inflamed  membrane  is 
paler  than  normal,  softened  from  (Edematous  infiltration,  and  otherwise 
altered.  The  effusion  poured  out  into  the  cavity  assumes  various  ap- 
pearances and  characteristics.  The  quantity  varies  from  a  few  ounces, 
in  the  dependent  parts  of  the  cavity,  up  to  several  gallons.  It  may  be 
sufficient  to  force  up  the  diaphragm  to  a  level  with  the  third  rib,  make 
the  heart  lie  transversely  by  pushing  up  the  apex,  displace  the  lungs, 
etc.  The  effusion  may  be  chiefly  fibrinous  with  but  little  fluid.  When 
this  is  the  case,  the  thickest  deposits  are  seen  over  the  solid  organs,  the 
liver  and  spleen,  and  it  may  be  general,  uniting  the  whole  surface,  or 
limited  in  extent,  forming  occasional  adhesions.  The  neo-membrane 
contains  vessels,  often  of  considerable  size,  and  having  walls  of  ex- 
ceeding tenuity.  These  vessels  rupture  easily,  and  considerable  haem- 
orrhage results,  and  this,  mixed  with  the  effusion,  constitutes  another 
form,  the  so-called  haemorrhagic  effusion.  The  adhesions,  when  iso- 
lated and  not  general,  undergo  great  changes  ultimately,  by  reason  of 
the  extensive  motion  possessed  by  the  abdominal  organs.  They  may, 
by  subsequent  contraction,  cause  great  deformity  of  organs  and  seri- 
ously impair  their  functions,  and  in  the  case  of  the  intestine  may 
induce  twisting,  encroach  on  their  caliber,  and  bring  about  slow  occlu- 
sion. The  small  intestines  may  by  means  of  such  adhesions  be  agglu- 
tinated together,  forming  an  almost  solid  mass,  irregularly  rounded,  as 
the  author  has  seen,  in  certainly  one  well-marked  case.  The  effusion 
may  be  serous — a  faint  greenish,  or  greenish-yellow,  or  milky  fluid, 
similar  to  the  fluid  of  ascites,  except  in  the  presence  of  flocculi  of 
fibrin,  bits  of  false  membrane,  and  casts  of  cells  of  the  endothelium. 
The  effusion  is  sero-fibrinous,  when  there  is  a  large  quantity  of  fibrin 
suspended  in  it.  When  absorption  of  the  fluid  takes  place,  the  solid 
exudation  undergoes  the  changes  already  described.  The  effusion  may 
be  purulent.  When  this  is  the  product  of  the  inflammation,  its  cause 
is,  as  a  rule,  perforation  and  the  escape  of  purulent  or  decomposing 
matters  into  the  peritoneal  cavity.  When  the  effusion  is  purulent,  the 
amount  of  fluid  contained  in  the  abdomen  varies  greatly.  There  may 
be  thick  masses  of  pus,  or  the  pus  may  be  mixed  with  a  quantity  of 
serum,  constituting  a  sero-purulent  fluid. 


I 


PERITONITIS.  127 

The  changes  of  chronic  peritonitis  are  similar  to  those  of  the  acute 
form.  There  is  often  little  or  no  fluid  exudation,  and  when  present  is 
not  abundant,  and  has  a  purulent  or  sero-purulent  form.  The  princi- 
pal fact  is  the  existence  of  false  membrane,  either  general  or  in  local 
bands.  The  intestines,  as  already  described,  are  sometimes  united  in 
a  bundle  and  form  a  globular  mass  of  some  compactness.  Occasion- 
ally a  part  of  the  neo-membrane,  especially  where  it  has  attained  the 
greatest  thickness,  undergoes  a  calcareous  transformation  ;  or  it  may 
become  soft,  friable,  and  granular,  doubtless  preparatory  to  absorp- 
tion, or  it  may  be  converted  into  connective  tissue.  Divided  by  mem- 
branous adhesions,  the  cavity  of  the  peritoneum  maybe  converted  into 
various  secondary  cavities,  some  containing  serous  and  others  purulent 
collections.  The  latter  may  be  converted  ultimately  into  a  cheesy 
mass.  In  chronic  peritonitis,  tubercular  deposit  is  common,  and  gray 
granulations  are  disseminated  through  the  false  membrane  and  the 
sub-serous  connective  tissue.  Tuberculous  peritonitis. is  usually  con- 
nected with  tuberculous  ulceration  of  the  mucous  membrane  of  the 
intestine,  and  tubercular  adenitis  of  the  mesentery,  and  is  coincident 
with  pulmonary  tuberculosis. 

Symptoms. — When  idiopathic  or  primary  peritonitis  occui-s  in  a 
previously  healthy  individual,  it  sets  in  with  a  chill,  an  intense  fever, 
and  very  severe  local  pain  and  tenderness.  If  it  succeeds  to  a  perfora- 
tion, the  onset  of  the  peritoneal  mischief  is  announced  by  an  intense 
pain,  felt  in  the  region  of  the  accident,  and  rapidly  extending  thence 
over  the  abdomen.  Then  the  fever  movement  is  but  slight.  If  peri- 
tonitis from  perforation  happens  in  the  course  of  typhoid  fever,  or  in 
any  other  adynamic  state,  there  may  be  few  symptoms  besides  disten- 
tion of  the  abdomen  and  increase  of  the  adynamia.  When  it  results 
from  an  extension  of  inflammation  by  contiguity  of  tissue,  it  is  an- 
nounced by  an  exaggeration  of  the  fever,  by  pain  and  tenderness  of 
the  abdomen,  and  by  vomiting — the  last-named  symptom  being  espe- 
cially significant  if  it  has  not  existed  in  the  case  previously.  In  what 
mode  soever  peritonitis  may  begin,  the  symptoms  most  characteristic 
are,  pains  in  the  abdomen,  gaseous  distention,  rapid  failure  of  strength, 
and  fever,  somewhat  remittent  in  type,  with  the  remission  in  the 
morning.  The  pain  in  the  abdomen  is  usually  an  intense,  cutting,  bor- 
ing pain,  somewhat  more  severe  at  certain  places,  but  felt  all  over  the 
abdomen.  The  slightest  touch  aggravates  the  pain,  and  hence  the 
patient  avoids  movement,  suppresses  cough,  and  breathes  with  the 
chest-muscles.  For  the  same  reason  the  breathing  is  short,  quick,  and 
superficial,  to  avoid  motion  of  the  diaphragm.  The  decubitus  of  the 
patient  is  unconsciously  assumed  to  prevent  pressure  of  the  muscles  on 
the  tender  peritoneum.  He  lies  on  his  back,  if  the  peritonitis  is  gen- 
eral, with  the  thighs  flexed  on  the  pelvis  and  the  shoulders  elevated, 
and,  when  he  is  told  to  extend  the  limbs,  he  does  so  very  cautiously  and 


128  DISEASES   OF   THE   PERITONEUM. 

soon  abandons  the  attempt,  his  countenance  as  well  as  his  expressions 
indicating  the  increased  pain  the  effort  has  given  him.  In  the  begin- 
ning of  the  disease,  the  abdominal  muscles  are  kept  contracted  and  rigid 
to  guard  the  peritoneum  from  injury  by  movement,  but  it  is  also  a  re- 
flex state  of  tonic  muscular  contraction,  which  occurs  simultaneously  in 
the  muscular  layer  of  the  bowel,  and  is  due  to  the  irritation  of  the 
terminal  nerve-filaments  in  the  pei'itoneum.  But  paresis  of  the  bowel 
soon  succeeds  to  tonic  rigidity,  in  accordance  with  another  law — over- 
stimulation, or  long-continued,  exhausts  the  irritability  of  the  organic 
muscular  fiber.  The  bowel  then  becomes  extended  by  the  accumu- 
lating gas,  and  soon  (on  the  second  or  third  day)  an  extreme  degree 
of  meteorism  is  the  result,  which,  in  fatal  cases,  continues  up  to  death. 
This  extreme  distention  of  the  abdomen  adds  to  the  difficulty  and  pain 
of  breathing.  The  sonority  of  the  percussion-note  is  tympanitic  over 
the  course  of  the  large  intestine  especially,  and  the  abdomen  generally, 
except  the  dependent  parts  in  the  flanks  and  iliac  fossse,  where  the 
accumulation  of  fluid  imparts  to  it  the  character  of  dullness.  The 
normal  hepatic  dullness  lessens  materially  or  disappears,  because  of 
the  displacement  of  the  liver  upward  and  its  partial  rotation  on  its 
long  axis.  The  position  of  the  dullness  on  percussion  varies  with  the 
changes  of  position  of  the  patient.  It  is  occasionally  possible  to  hear 
a  friction-sound  by  auscultation,  but  the  duration  of  it  in  any  case  is 
very  brief.  The  tongue  is  coated  and  the  appetite  impaired  at  the 
onset.  Rarely  is  vomiting  absent.  It  begins  soon  after  the  disease 
sets  in,  and  at  first  articles  of  food  and  gastric  mucus  come  up,  then 
biliary  matters  from  the  duodenum.  Vomiting  may  occur  sponta- 
neously, or  be  excited  by  taking  medicine,  food,  or  drink.  In  some 
rare  cases  the  vomiting  has  been  incessant,  and  finally  stercoraceous. 
In  such  cases  obstruction  is  supposed  to  exist,  but  not  confirmed  on 
post-mortem  examination,  only  peritonitis  being  found.  Constij)ation 
is  the  rule  in  case  of  peritonitis,  but  occasionally  diarrhoea  is  present  ; 
then,  usually,  some  coincident  disease  of  the  bowel  exists,  as  tubercu- 
losis or  septicaemia,  for  example.  Constipation  is  the  necessary  result 
of  the  paresis  of  the  bowel ;  but  paralysis  of  the  sphincter  may  be  so 
complete  as  to  permit  the  escape  of  fecal  matters  by  mere  pressure  on 
the  abdomen.  An  extension  of  inflammation  to  the  vesical  peritoneum 
causes  strangury  and  irritable  bladder.  Hiccough  is  a  frequent  and 
most  distressing  symptom,  and  is  due  to  a  reflex  irritation  of  the 
diaphragm,  transmitted  from  the  nerve-endings  in  the  i3eritoneum. 
The  pulse  in  peritonitis  is  small,  quick,  and  frequent,  the  tension  high. 
When  cardiac  failure  comes  on  in  fatal  cases  it  becomes  excessively 
quick  and  small,  and  may  disappear  at  the  wrist  when  the  heart  is 
still  acting.  It  will  range  in  ordinary  cases  from  100  to  140  ;  when 
collapse  approaches,  the  pulsations  may  reach  160  to  200.  When  col- 
lapse comes  on,  the  tempei'ature,  which  had  risen  to  103°  Fahr.,  sinks 


PERITONITIS.  129 

below  normal.  As  has  been  already  pointed  out,  the  respirations  are 
costal  in  type,  very  shallow,  and  becoming  more  so  with  the  failure 
of  the  vital  powers.  There  is  then  cyanosis.  The  countenance  is 
anxious,  shrinks  ;  dark,  livid  circles  surround  the  eyes.  In  collapse  the 
surface  is  cold,  wet  with  a  cold  sweat,  the  skin  wrinkled  and  sodden, 
the  body  exhales  a  cadaveric  odor,  the  voice  is  husky,  but  the  mind 
remains  clear  though  rather  apathetic,  and  at  the  last  the  brain  is 
clouded  by  carbonic-acid  poisoning.  Or,  instead  of  an  unclouded 
intellect,  there  may  be  delirium  from  oedema  of  the  brain,  and,  ex- 
tremely rarely,  unconsciousness  soon  after  the  onset  of  symptoms.  In 
many  cases,  as  collapse  develops,  the  peculiar  type  of  respiration — the 
Cheyne-Stokes  respiration — appears,  and  is  highly  significant  of  a  fatal 
termination. 

Course,  Duration,  and  Terminations. — The  course  of  peritonitis  is 
rapid,  the  mortality  great.  The  usual  termination  is  in  death.  When 
it  arises  from  perforation,  a  fatal  result  may  occur  in  two  or  three 
days,  and,  when  it  is  idiopathic,  in  five  or  six ;  but  the  cases  of  this 
variety  last  two  to  three  weeks.  Peritonitis  due  to  internal  obstruc- 
tions adds  to  the  severity  of  the  symptoms  and  the  gravity  of  the 
case,  but  its  course,  apart  from  the  principal  malady,  is  not  well  de- 
fined. The  gravest  cases  are  those  which  occur  in  the  course  of  septic 
diseases,  or  are  due  to  the  escape  of  decomposing  and  irritating  matters, 
by  a  perforation  into  the  cavity.  The  only  forms  which  may  be  re- 
garded as  at  all  favorable  are  those  due  to  the  extension  of  a  simple 
inflammation,  by  contiguity  of  tissue,  from  the  abdominal  or  pelvic 
viscera.  In  these  the  inflammation  is  simply  exudative  and  adhesive, 
or  sero-fibrinous.  "When  improvement  begins,  it  is  announced  by  a 
diminution  of  the  pain,  lessening  of  the  meteorism,  and  cessation  of 
the  vomiting.  A  case  of  acute  peritonitis  may  terminate  in  a  chronic 
form  of  the  disease.  After  a  period  of  improvement,  grave  symptoms 
will  again  set  in,  induced  by  the  changes  in  shape,  position,  and  func- 
tions of  organs,  the  result  of  adhesions,  contractions  of  bands  of  lymph, 
etc. 

Prognosis. — The  statements  already  made  sufficiently  set  forth  the 
grave  character  of  jDcritonitis.  The  prognosis  in  the  mildest  cases 
must  be  guarded,  and  in  all  severe  cases  unfavorable. 

Diagnosis.  — Peritonitis  is  to  be  differentiated  from  hysterical  ten- 
derness of  the  abdomen,  rheumatism  of  the  abdominal  muscles,  and 
acute  painful  affections  of  the  various  organs.  From  hysteria  it  is  dif- 
ferentiated by  the  hysterical  history,  by  the  crying,  sobbing,  and  globus 
hystericus,  by  the  absence  of  all  constitutional  symptoms,  and  finally  by 
the  tenderness  being  merely  an  hysterical  condition,  excessive  on  the 
surface,  but  permitting,  when  the  attention  is  withdrawn,  firm,  deep 
pressure.  The  suffering  of  the  hysterical  state  differs  from  real  pain 
in  the  disproportion  of  the  expressions  and  the  evidences  ;  while  the 
9 


130  DISEASES   OF   THE  PERITONEUM. 

most  extravagant  terms  are  used  to  describe  the  pain,  the  countenance 
is  placid.  In  rheumatism  of  the  abdominal  muscle,  there  will  probably 
have  been  other  cases  of  the  rheumatismal  character  ;  the  pain  is  lim- 
ited to  the  muscles,  and  deep  pressure  does  not  increase  it,  and  the  con- 
stitutional state  does  not  indicate  a  severe  disease.  In  acute  painful 
affections  it  is  sometimes  difficult  at  once  to  decide,  but  as  a  rule  these 
begin  rather  more  abruptly,  the  pain  is  more  acute,  and  there  is  not 
usually  a  history  of  a  disease  from  which  peritonitis  might  be  expected 
to  arise.  The  great  majority  of  cases  of  peritonitis  arise  from  previous 
disease  in  the  peritoneal  or  pelvic  cavities  ;  it  is  extremely  rare,  indeed, 
for  an  idiopathic  case  to  occur. 

CHRONIC  PERITONITIS. — There  are  two  forms  :  1.  Succeeding 
to  the  acute  ;  2.  Tubercular.  The  acute  symptoms  subside  and  there 
is  a  gradual  absorption  of  the  fluid  portion  of  the  exudation.  A  sero- 
fibrinous exudation  may  undergo  conversion  into  a  purulent ;  the 
fever,  which  had  diminished  or  ceased,  rises  again  and  takes  on  the 
septicsemic  character — there  are  chills,  fever,  and  sweats.  Rapid  de- 
cline of  the  vital  powers  takes  place  under  these  circumstances.  Or 
the  effusion  may  become  encysted  by  the  formation  of  adhesions,  as 
already  described,  and  become  a  pus-depot,  which  may  be  converted, 
ultimately,  into  a  caseous  or  calcareous  mass.  In  other  cases  these 
purulent  collections  behave  as  ordinary  abscesses,  and  manifest  a  ten- 
dency to  find  their  way  externally.  Abscesses  formed  above  a  line 
drawn  transversely  across  the  abdomen  through  the  umbilicus  tend 
to  dissect  upward,  and  make  their  way  out  through  the  lungs  ;  those 
below  this  line  tend  to  pass  down  along  the  course  of  the  femoral  ves- 
sels. Although  there  are  many  exceptions,  this  may  be  considered  as 
a  natural  tendency.  In  the  dissections  made  by  these  abscesses,  fis- 
tulse  may  be  established  externally,  with  different  parts  of  the  bowel, 
with  the  thoracic  cavity,  etc.  ;  or  rupture  may  occur  into  the  perito- 
neal cavity,  again  exciting  fresh  inflammation.  The  chronic,  local,  and 
partial  peritonitis,  about  certain  organs,  may  set  up  important  changes 
by  the  metamorphoses  of  the  exudation.  Thus,  thick  and  contracting 
connective  tissue  about  the  gall-bladder,  and  on  the  upper  surface  of 
the  liver,  compresses  the  organ,  or  may  obstruct  the  hepatic  duct  or  the 
portal  vein.  The  tubercular  form  of  chronic  peritonitis  is  often  asso- 
ciated with  the  corresponding  disease  of  the  lungs,  or  intestinal  mucous 
membrane,  or  of  both.  Its  onset  is  obscure,  and  development  slow,  so 
that  weeks  or  even  months  may  pass  before  the  patient  is  so  reduced 
as  to  take  to  his  bed.  It  usually  sets  in  by  colicky  pains  felt  ejjpecially 
during  the  time  digestion  is  going  on.  Constipation  alternates  with 
diarrhoea,  and  there  may  be,  but  not  invariably,  attacks  of  vomiting,  the 
matters  thrown  up  consisting  of  mucus  and  greenish,  bilious-looking 
matter.    The  attacks  of  vomiting  may  coincide  with  the  colic-like  pains. 


PERITONITIS.  13j^ 

The  patient  rapidly  declines  in  flesh  and  strength.  There  are  daily 
chilliness  and  febrile  movement.  The  skin  is  harsh  and  dry  ;  sweating 
usually  occurs  at  night  ;  the  urine  is  scanty,  high  colored,  and  deposits 
an  abundant  uric-acid  sediment.  With  the  development  of  these 
symptoms  the  abdomen  gradually  assumes  a  characteristic  condition. 
By  the  accumulation  of  gas  in  the  intestine,  and  of  serous  effusion  in 
the  cavity,  the  abdomen  enlarges.  Notwithstanding  a  considerable 
effusion,  it  is  rare  that  the  signs  and  symptoms  of  ascites  are  present. 
There  is  dullness  in  the  dependent  parts,  whatever  may  be  the  decubi- 
tus of  the  patient,  but  not  such  a  fluctuation  as  occurs  in  ascites.  The 
compression  of  the  vessels,  by  the  effusion  within  and  the  direct  pres- 
sure of  membranous  adhesions,  but  especially  the  matting  of  the  small 
intestines  into  a  globular  mass,  and  the  pressure  of  this  tumor-like 
body  on  the  iliac  veins,  cause  an  extensive  oedema  of  the  lower  ex- 
tremities, the  scrotum,  and  the  abdominal  walls.  This  result  is  pro- 
moted by  the  enlargement  of  the  mesenteric  glands,  which  are  also 
occupied  by  tubercular  deposit.  The  course  of  this  malady  is  slow, 
but  the  termination  by  death  is  not  less  certain.  The  reader  should 
not  overlook  the  distinction  between  a  tubercular  peritonitis  occurring 
with  tubercular  phthisis  and  other  tubercular  diseases  and  a  peri- 
tonitis in  which  tubercular  deposit  is  secondary  to  the  morbid  process 
which  had  preceded  it. 

Treatment. — When  robust  subjects  are  attacked  by  peritonitis,  there 
can  be  no  doubt  of  the  utility  of  leeches,  ten  to  twenty  applied  over 
the  abdomen.  In  the  cases  of  local  peritonitis  (typhlitis,  for  example), 
if  the  patient  is  not  very  weak,  leeches  ai'e  highly  serviceable.  There 
are  few,  indeed,  who  can  not  bear  the  loss  of  blood  of  two  or  three 
leeches.  The  time  for  their  application  is  the  onset  of  the  disease, 
before  solid  exudations  have  occurred.  After  leeches,  or  at  once, 
an  ice-bag  should  be  applied  to  the  abdomen,  or  to  the  part  only  af- 
fected. This  ceases  to  be  useful,  and  is  better  supplanted  by  warm  ap- 
plications, when  exudations  take  place  and  the  abdomen  swells.  With 
the  first  symptoms,  morphia  should  be  administered  hypodermatically, 
and  should  be  repeated  eveiy  four,  six,  or  eight  hours  according  to  the 
effect,  such  a  degree  of  narcotism  being  maintained  that  pain  is  re- 
lieved, the  pulse  considerably  reduced,  but  yet  the  patient  is  easily 
roused.  Atropia  should  be  given  with  the  morphia.  The  very  heroic 
use  of  morphia,  advocated  in  some  quarters,  is  not  to  be  commended. 
The  best  curative  results  are  obtained  from  doses  that  affect  decidedly 
without  inducing  a  degree  of  narcotism  that  may  be  dangerous.  At 
the  very  beginning,  the  administration  of  antipyretic  doses  of  quinia 
is  in  a  high  degree  beneficial,  and  the  effect  may  be  maintained  by  fre- 
quent exhibition  of  smaller  doses.  This  ceases  to  be  useful  when  there 
is  solid  and  liquid  exudation.  When  effusion  occurs,  another  and  a 
very  different  kind  of  medication  must  be  adopted.     The  decline  of 


132  DISEASES   OF   THE   PERITONEUM. 

the  vital  powers  must  be  retarded  by  suitable  nutrients  and  stimulants. 
The  local  applications  should  consist  of  warm  fomentations,  mustard- 
plasters,  or  flying-blisters,  or  the  tincture  of  iodine.  By  the  stomach 
the  salts  of  ammonia  should  be  administered,  and  freely,  and  morphia 
continued  />ro  re  nata.  Ten  grains  of  the  carbonate  of  ammonium, 
in  an  ounce  of  the  solution  of  the  acetate,  every  four  hours,  when 
the  exudation  is  going  on,  is,  the  author  believes,  a  remedy  of  the 
highest  utility.  In  the  peritonitis  from  perforation,  absolute  repose, 
opium,  ice,  and  the  avoidance  of  all  foods  and  drinks,  are  the  proper 
measures. 

ASCITES— DROPSY    OF    THE    ABDOMEN. 

Causes. — The  chief  factor  in  the  pathogeny  of  ascites  is  mechani- 
cal obstruction  of  the  vessels,  the  portal  system,  and  the  most  common 
cause  of  this  obstruction  is  cirrhosis  of  the  liver.  Tumors,  as  aneu- 
rism of  the  hepatic  artery,  tubercle  masses,  cancer,  and  hydatids,  in  a 
situation  to  compress  the  portal  vein,  will  also  cause  an  effusion  into 
the  peritoneal  cavity.  Increase  of  pressure  in  the  portal  system  may 
be  due  to  obstructive  disease  of  the  heart  or  lungs.  Again,  dropsy  of 
the  peritoneum  may  be  a  part  of  general  dropsy,  especially  in  chronic 
nephritis.  Accumulation  of  fluid  is  a  result  of  peritonitis,  acute  or 
chronic,  but  this  does  not,  properly,  constitute  ascites. 

Pathological  Anatomy. — The  amount  of  effusion  which  exists  in 
ascites  varies  from  a  few  ounces  to  many  gallons.  It  is  usually  of  a 
pale  straw-color,  or  it  may  have  a  greenish  tint,  and  is  transparent, 
and  may  be  free  from  flocculi,  or  any  foreign  constituents.  Its  reac- 
tion is  alkaline,  and  its  specific  gravity  below  that  of  the  serum  of  the 
blood.  It  contains  albumen  or  albuminate  of  soda,  but  the  proportion 
is  less  than  is  present  in  the  blood-serum,  but  greater  than  other  serous 
exudation  except  hydrothorax.  The  biliary  acids  and  pigment  are  also 
foi^nd  in  the  ascitic  fluid,  when  jaundice  exists,  and  creatine  and  crea- 
tinine are  very  common  constituents.  In  many  cases  fibrin  is  held  in 
solution,  and  slowly  coagulates  in  an  exceedingly  fine  reticulation  of 
fibers.  Sometimes  ascitic  fluid  is  reddish  from  the  presence  of  blood 
derived  from  ruptured  capillaries  ;  again,  blood  may  indicate  the 
probability  of  cancer.  The  peritoneum  long  in  contact  with  fluid  is 
altered  in  character  and  appearance  by  imbibition  ;  it  becomes  sodden, 
cloudy,  and  thickened,  but  these  are  not  inflammatory  changes.  The 
distention  of  the  cavity  and  the  displacement  of  organs  disturb  the 
relation  of  the  parts. 

Symptoms. — As  a  rule  the  beginning  of  ascites  is  obscure,  and  it  is 
not  discovered  until  the  sense  of  fullness  and  tension  directs  attention 
to  the  part,  or  an  examination  of  the  abdomen  is  made  for  the  pur- 
pose, existing  lesions  rendering  it  probable  that  effusion  has  occurred. 
An  increasing  fullness  of  the  abdomen  is  the  most  important  objective 


ASCITES.  133 

symptom.  It  is  not  wholly  fluid,  but  the  distention  is  in  part  due  to 
flatus  in  the  intestines  and  fecal  accumulations,  the  result  of  consti- 
pation caused  by  pressure  on  the  sigmoid  flexure.  If  the  patient  is 
erect,  the  fluid  distends  the  iliac  and  hypogastric  regions  ;  if  lying 
down,  the  fluid  flows  to  the  sides ;  if  turned  upon  one  side,  the  fluid 
takes  a  corresponding  position — so  that  the  dullness  on  percussion  varies 
with  the  posture  of  the  patient.  With  the  increase  in  the  amount  of 
fluid  the  girth  of  the  abdomen  enlarges,  so  that  in  cases  of  large  effu- 
sion the  abdomen  may  be  two  or  three  times  larger  than  the  normal. 
When  the  effusion  is  great  and  of  long  standing,  the  umbilicus  is 
forced  outwardly,  and  forms  a  tumor  with  thin  walls,  and  soft  and 
fluctuating  in  character.  The  physical  signs  are  characteristic  :  On 
mensuration,  the  increased  circumference  ;  on  palpation,  a  peculiar 
wave-impulse  communicated  through  the  intervening  fluid,  when  a 
slight  blow  is  made  on  one  side  ;  on  percussion,  a  tympanitic  note 
over  the  distended  bowel,  and  a  region  of  perfect  dullness  correspond- 
ing to  the  position  of  the  fluid.  The  wave  of  fluctuation  is  best  felt 
by  laying  the  hand  extended  flat  on  one  side  of  the  abdomen,  and 
gently  tapping  the  opposite  side.  The  distended  abdomen  forces  the 
diaphragm  upward  and  therefore  embarrasses  the  respiration  and  the 
cardiac  movements  ;  the  urinary  secretion  is  diminished  because  of 
the  pressure  on  the  renal  arteries  and  veins,  and  of  the  escape  of  fluid 
into  the  peritoneal  cavity  ;  constipation  I'esults  from  the  compression 
of  the  sigmoid  flexure.  The  integument  of  the  abdomen  has  a  glis- 
tening appearance,  arising  from  stretching  and  cedema,  but  the  skin 
generally  is  harsh  and  dry.  The  lower  extremities  and  the  scrotum 
also  are  much  sw^ollen,  when  the  ascitic  fluid  is  sufficient  in  weight  to 
compress  the  vena  cava  and  iliacs. 

Course,  Duration,  and  Termination. — The  course  and  behavior  of 
ascites  depend  much  on  the  cause  producing  it.  Usually  the  effusion 
occurs  slowly,  as,  for  example,  in  cirrhosis,  in  which  disease  there  may 
be  months  occupied  in  producing  sufficient  effusion  to  distend  the  ab- 
domen. In  idiopathic  ascites,  the  accumulation  may  take  place  in  one 
or  two  weeks.  The  amount  of  increase  in  the  blood-pressure  may 
vary  greatly  when  an  obstruction,  cardiac,  pulmonary,  or  hepatic,  is  the 
cause  of  the  effusion.  Idiopathic  ascites  is  shorter  in  duration  than 
the  other  forms,  and  terminates  in  health  in  a  few  weeks.  The  dura- 
tion of  the  other  forms  is  a  question  of  the  course  and  behavior  of  the 
malady,  of  which  ascites  is  usually  a  symptom.  When  dependent  on 
obstructive  disease  of  the  heart,  lungs,  or  liver,  especially  the  liver, 
the  duration  is  indefinite.  The  fluid  may  be  removed  by  treatment, 
and  return  again  and  again,  for  the  original  cause  remains. 

Prognosis. — The  question  of  recovery  is  determined  by  the  presence 
or  absence  of  certain  organic  changes.  If  the  effusion  is  simply  peri- 
toneal, the  prognosis  may  be  favorable.     If  it  is  a  symptom  of  cardiac. 


134  DISEASES   Or   THE   PERITONEUM. 

pulmonary,  or  hepatic  disease,  the  prognosis  is  unfavorable,  for  these 
maladies  being  incurable  the  effusion  will  recur,  if  at  any  time  it  may 
be  removed. 

Diagnosis. — Ascites  must  be  differentiated  from  ovarian  tumors, 
pregnancy,  distended  bladder,  chronic  peritonitis,  and  enlarged  spleen. 
As  ovarian  tumors  are  so  often  accompanied  by  effusion  into  the  peri- 
toneal cavity,  mistakes  are  frequent,  ovarian  tumors  being  confound- 
ed with  ascites,  and  vice  versa.  The  distinction  lies  in  the  following 
considerations  :  Ascites  is  almost  always  preceded  by  obstructive 
diseases  of  the  heart,  lungs,  or  liver,  especially  by  cirrhosis,  and  the 
derangements  of  health  which  the  existence  of  these  obstructive  dis- 
eases always  implies.  Ovarian  disease  does  not  necessarily  impair  the 
health,  and  is  not  preceded  or  accompanied  by  the  lesions  pertaining 
to  ascites. 

In  ascites  the  enlargement  of  the  abdomen  is  uniform,  begins  at 
the  dependent  part,  whatever  that  may  be,  and  the  dullness  on  percus- 
sion changes  with  the  position  of  the  patient  ;  ovarian  tumor  begins 
in  the  iliac  fossa  of  either  side,  the  growth  is  obliquely  upward,  does 
not  change  its  position  according  to  the  posture  of  the  patient,  nor 
does  the  dullness  change.  The  tympanitic  percussion-note,  derived 
from  percussion  over  the  distended  intestines,  is  in  ascites  above  the 
fluid  ;  in  ovarian  tumor,  to  the  side  and  behind.  When  fluid  in  the 
cavity  coincides  with  a  tumor,  the  latter  may  be  felt  by  suddenly  dis- 
placing the  fluid,  and  coming  down  on  the  tumor  with  the  hand.  An 
exploration  through  the  rectum,  by  the  method  of  Simon,  will  enable 
a  diagnosis  to  be  made  at  once  ;  by  conjoined  manipulation  through 
the  vagina,  a  tumor  can  usually  be  easily  defined.  In  pregnancy  the 
tumor  develops  in  the  middle  line  of  the  abdomen  with  an  inclination 
to  the  right ;  it  is  firm,  inelastic,  and  non-fluctuating.  Changes  in  the 
length,  density,  and  size  of  the  neck  of  the  uterus,  and  in  its  functions 
(arrest  of  menstrual  flow),  and  in  the  mammae,  with  the  other  evidences 
of  pregnancy,  accompany  the  growth  of  the  uterine  tumor.  After  the 
fourth  month  the  sounds  of  the  foetal  heart  and  the  placental  souffle, 
together  with  the  hallottement,  indicate  the  nature  of  the  case  without 
doubt.  The  author  has  known  a  distended  bladder  mistaken  for  ascites. 
Applying  the  same  method  already  described  for  the  diagnosis  between 
ovarian  tumor  and  ascites,  the  difference  becomes  at  once  apparent. 
In  all  cases  of  critical  examination  of  the  pelvic  organs,  the  catheter 
is  used,  or  ought  to  be,  to  prevent  error  and  to  facilitate  the  exploration. 
The  local  and  physical  signs  may  be  precisely  the  same  in  ascites  and 
chronic  peritonitis,  but  the  clinical  history  is  so  different  that  a  differen- 
tiation may  be  made  by  reference  to  the  origin,  causes,  and  symptoma- 
tology of  the  two  affections.  Peritonitis  is  accompanied  by  pain  and 
tenderness  of  the  abdomen,  by  an  increased  thickness  of  the  walls,  by 
persistent  vomiting,  and  by  alternating  constij^ation  and  diarrhoea  ;  in 


ASCITES.  135 

ascites  there  is  usually  no  tenderness,  the  walls  of  the  abdomen  be- 
come very  thin  from  absorption  of  fat  and  atrophy  of  the  muscles, 
there  is  no  vomiting  except  such  as  is  due  to  hepatic  disease,  and  there 
is  persistent  constipation.  The  spleen  may  be  uniformly  and  exten- 
sively enlarged  so  as  to  fill  the  cavity,  but  it  differs  from  ascites  in  the 
following  particulars  :  The  enlargement  is  from  the  left  hypochon- 
drium  downward  ;  it  is  firm,  inelastic,  and  non-fluctuating  ;  the  dull- 
ness maintains  with  the  tumor  a  constant  position,  which  does  not  fol- 
low the  movements  of  the  patient. 

Treatment. — There  are,  besides  artificial  means,  two  outlets  to  the 
effusion — by  the  intestinal  canal  ;  by  the  kidneys. 

Dry  diet  has,  from  the  earliest  period,  been  regarded  as  a  most 
efiicient  plan  of  treatment.  As  it  may  be  tried  without  interfering 
with  the  remedial  management  proper,  it  should  be  enforced  in  suit- 
able cases.  Dry  diet  consists  in  absolute  disuse  of  fluids  of  every 
kind,  and  the  use  of  water-free  food.  It  is  extremely  irksome,  but,  if 
patiently  carried  out,  will  contribute  materially  to  relief  or  cure,  as 
either  may  be  practicable.  If  this  method  be  unavailable,  the  oppo- 
site plan,  or  the  free  use  of  water  and  diluents,  should  be  enjoined. 
The  best  of  all  diluents  for  this  purpose  is  skimmed  milk,  which 
should  be  taken  with  regularity  and  in  as  large  quantity  as  the  pa- 
tient can  bear.  An  intelligent  medicinal  treatment  of  ascites  must 
be  conducted  with  reference  to  its  cause.  Here  only  the  remedies  for 
the  removal  of  the  effusion  can  be  discussed.  As  the  cavity  is  a  closed 
sac,  diuretics  are  not  very  efiicient.  The  treatment  by  hydragogue 
carthartics  is  the  most  generally  serviceable,  and  of  the  remedies  be- 
longing to  this  group  the  most  useful  is  the  compound  jalap  powder. 
Several  watery  evacuations  must  be  passed  daily  to  make  any  impor- 
tant impression  on  the  effusion  ;  this  result  is  most  easily  accomplished 
by  the  administration  of  one  or  two  drachms  of  the  compound  jalap 
powder  in  the  early  morning,  to  avoid  interference  with  the  digestion. 
If  the  jalap  is  not  efficient,  elaterium  may  be  substituted  ;  but  in  the 
author's  experience  the  former  is  to  be  preferred.  Notwithstanding 
the  little  utility  of  diuretics,  advantage  should  be  taken  of  any  good 
arising  from  them.  Bitartrate  of  potassa,  in  the  form  of  cream-of- 
tartar  lemonade,  is  an  excellent  diluent,  unless  the  dry  diet  is  used. 
Digitalis,  especially  in  the  form  of  infusion,  is  the  best  of  the  diuretics 
proper.  These  remedies  may  be  given  jointly.  To  urge  the  kidneys 
to  their  highest  activity,  the  functions  of  the  skin  should  not  be  ex- 
cited, and  the  cutaneous  capillaries  must  therefore  be  kept  contracted 
by  lessening  the  warmth  of  the  covering  or  clothing.  An  increased 
action  of  the  skin  is  generally  more  serviceable  in  ascites  than  diuretics 
are,  unless  an  obstructive  cardiac  or  pulmonary  disease  is  the  cause  of 
the  effusion.  Most  excellent  results  are  now  obtained  from  the  use  of 
jaborandi  or  pilocarpine  in  the  treatment  of  ascites.     Warm  clothing, 


l^Q  DISEASES   OF   THE   PANCREAS. 

vapor-baths,  and  pilocarpine  may  be  used  jointly,  to  maintain  constant 
diaphoresis.  Removal  of  the  fluid  by  tapping  is  a  useful  expedient  in 
cases  not  relieved  by  the  methods  advised,  but  so  rapidly  does  reac- 
cumulation  take  place  that  this  measure  should  not  be  practiced  too 
early.  It  should  not  be  adopted  until  the  embarrassment  of  breathing 
is  so  great  as  to  prevent  sleep.  The  relief  it  affords  is  immense,  and 
is  accomplished  now  so  readily  that  there  is  a  constant  temptation  to 
employ  the  aspirator  trocar  before  the  proper  time  has  arrived.  The 
puncture  is  made  in  the  middle  line — the  Unea  alba — two  or  three 
inches  below  the  umbilicus.  It  is  not  necessary  to  draw  off  all  the 
fluid,  but  a  sufficient  quantity  to  afford  relief.  The  puncture  should 
be  carefully  closed.  It  is  sometimes  difficult  to  do  this,  and  the 
ascitic  fluid  is  permitted  to  drain  away  indefinitely ;  but  the  prac- 
tice is  bad,  for  the  admission  of  air  to  the  cavity  sets  up  a  septic  pro- 
cess, and  may  excite  a  fatal  peritonitis,  as  the  author  has  seen. 

IDIOPATHIC  SUPPURATIVE  PERITONITIS  is  a  term  applied  to 
a  form  of  peritonitis  apparently  arising  from  exposure  to  cold,  and  oc- 
curring in  children.  It  has  the  clinical  history  of  peritonitis — sudden 
onset,  fever,  small  pulse  (dicrotic),  rapid  decline  in  strength,  pain  in  the 
abdomen,  meteorism,  nausea  and  vomiting,  constipation,  vesical  tenes- 
mus. Pus  may  be  evacuated  through  the  rectum,  bladder,  vagina,  or 
externally.  It  is  in  a  high  degree  probable  that  the  peritonitis  is  not 
a  primary  but  a  secondary  affection,  and  is  due  to  perforation.  The 
enormous  accumulation  of  gas  and  its  extreme  fetidity  lend  support 
to  this  view.  Other  cases  having  similar  symptoms,  and  terminating 
by  the  discharge  of  matter,  may  be  examples  of  the  subperitoneal 
phlegmon.* 


DISEASES    OF    THE    PANCREAS. 


PRELIMINARY  OBSERVATIONS.— So  little  is  definitely  known 
of  the  diseases  of  the  pancreas  that  many  systematic  wi'iters  omit 
the  subject  entirely.  There  are,  however,  some  practical  points  which 
should  receive  attention.  The  pancreas  has  an  office  in  connection 
with  the  digestion  of  certain  kinds  of  foods.  Like  the  salivary  secre- 
tion, the  pancreatic  fluid  transforms  starch  into  dextrine  and  grape- 
sugar.  Although  its  ferment  loses  its  activity  in  the  presence  of  an 
acid,  yet  the  pancreatic  juice  has  the  power  to  complete  the  digestion 

*  Sec  the  paper  by  M.  le  Dr.  Besnier,  "Arch.  Gen.  de  Med.,"  September,  1878. 


\ 


PANCREATITIS.  137 

of  peptones  that  have  escaped  final  action  of  the  gastric  juice.*  The 
emulsionizing,  or  preparation  of  fats  for  absorption,  is  another  func- 
tion of  the  pancreatic  fluid.  It  therefore  supplements  the  action  of 
all  the  digestive  juices.  This  fact  suggests  that  which  experiment 
has  demonstrated — that  the  pancreas  is  not  essential,  and  that  the  pro- 
cess of  digestion  can  be  carried  on  without  its  aid.  The  diseases  af- 
fecting the  pancreas,  in  regard  to  which  positive  information  exists, 
are  pancreatitis,  acute  and  chronic,  and  tumors  of  the  pancreas. 

PANCREATITIS.— In  the  acute  form,  the  changes  consist  in  hyper- 
a5mia,  increased  size  and  density  of  the  organ,  and,  it  may  be,  hasmor- 
rhagic  extravasation.  The  inflammation  proceeds  to  suppuration  in  a 
portion  of  the  cases,  at  first  in  isolated  depots,  which  may  subsequent- 
ly coalesce,  forming  a  large  one.  Peritonitis  may  arise  when  the 
superficial  parts  of  the  organ  are  occupied  hy  abscesses,  and  gangrene 
and  sloughing  may  ensue  when  there  is  considerable  haemorrhagic  ex- 
travasation. Almost  nothing  is  known  in  regard  to  the  causes  of  the 
disease.  Men  seem  to  be  more  frequently  affected  than  women.  As 
pancreatitis  seems  to  have  occurred  more  often  several  centuries  ago, 
it  is  highly  probable  that  the  excessive  use  of  mercury  was  an  efficient 
cause.  As  the  functions  of  the  pancreas  are  merely  auxiliary,  it  is  not 
surprising  that  but  few  symptoms  are  produced  when  the  organ  is  the 
seat  of  an  inflammation.  Pain,  becoming  very  acute  and  depressing,  is 
one  of  the  earliest  symptoms  ;  it  is  felt  in  the  epigastrium,  and  radiates 
to  either  shoulder  and  to  the  back  ;  there  are  restlessness,  precordial 
anxiety,  faintness,  nausea,  and  vomiting.  After  much  straining,  some 
bilious-looking  watery  fluid  is  brought  up,  but  this  does  not  afford 
relief.  There  is  considerable  gaseous  distention  of  the  abdomen,  and 
a  good  deal  of  gas  comes  up  by  eructation.  Constipation  is  also  a 
symptom,  f 

From  the  beginning  there  is  fever  ;  the  pulse,  at  first  full  and  tense, 
soon  becomes  small,  feeble,  and  irregular.  The  symptoms  of  depres- 
sion make  rapid  progress,  and  in  a  few  days  (four  to  six)  the  patient 
is  in  a  condition  of  collapse,  with  shrunken  features,  cold  surface,  cold 
extremities,  and  failing  heart.  The  marked  anxiety  and  depression 
from  the  first  and  the  weak  and  irregular  action  of  the  heart  indicate 
an  implication  of  the  solar  plexus  ;  for  similar  symptoms  are  produced 
artificially  (crushing-blow  exi^eriment).  It  Avill  be  difficult  to  distin- 
guish this  affection  from  hepatic  colic,  or  gastralgia,  except  by  the 
fever,  the  rapid  and  irregular  action  of  the  heart,  and  the  early  col- 
lapse, which  are  wanting  in  these  two  disorders,  which  also  terminate 
in  a  few  hours — one  with  jaundice  and  returning  health,  the  other 
■with  complete  relief  and  immediate  resumption  of  the  functions.     The 

*  Dr.  W.  Kiihne,  Virchow's  "  Archiv.,"  Band  xxxix,  p.  130. 

t  Oppolzer,  "  Uber  Krankheiten  des  Pancreas,"  "Wiener  med.  Wochen.,"  ISBT,  No,  1. 


138  DISEASES   OF   THE   PANCREAS. 

termination,  after  a  very  rapid  course,  is  usually  in  death  ;  but  there 
may  be  a  gradual  decline  into  a  chronic  state,  ending  in  abscess  or  slow 
induration.  Acute  pancreatitis  may  be  secondary  to  other  affections — 
there  may  occur  in  it,  during  the  course  of  acute  infectious  diseases, 
the  changes  included  in  the  term  parenchymatous  degeneration. 

The  chronic  interstitial  pancreatitis,  affecting  parts  of  the  gland, 
is  the  form  which  the  chronic  inflammation  most  usually  takes.  The 
connective  tissue  undergoes  hyperplasia,  and  the  proper  gland-struc- 
ture wastes.  When  the  whole  organ  is  involved,  there  may  be  an 
entire  disappearance  of  the  proper  gland-structure,  or  a  part  of  it  may 
be  converted  into  a  connective-tissue  bundle.  As  in  cirrhosis  of  the 
kidney,  cysts  are  formed  by  obstruction  of  ducts.  Calculi  form  in  the 
ducts,  and  the  duct  of  Wirsung  may  be  entirely  occluded  by  a  cal- 
culus, inducing  dilatation  of  the  ducts  and  atrophy  of  the  gland-sub- 
stance. Abscesses  may  also  result  from  the  pressure  and  inflamma- 
tion caused  by  calculi.  Chronic  j^arenchymatous  pancreatitis  is  a  less 
usual  form  of  chronic  inflammation.  It  is  probably  more  frequently 
secondary  than  primary — i.  e.,  due  to  the  extension  of  suppurative 
inflammation  from  neighboring  parts.  The  symptoms  are  most  in- 
definite. It  is  supposed  that  the  appearance  of  an  excess  of  fat  in 
the  stools,  salivation,  emaciation,  and  gastric  disturbances,  may  be  due 
to  chronic  inflammation  of  the  pancreas,  but  none  of  these  symptoms 
are  distinctive. 

The  treatment  must  be  entirely  symptomatic.  Pain  must  be  re- 
lieved by  morphia  hypodermatically,  the  stomach  symptoms  by  car- 
bolic acid,  bismuth,  pepsin,  ingluvin,  hydrocyanic  acid,  etc.,  and  the 
chronic  interstitial  change  is  best  treated  by  minute  doses  of  corrosive 
sublimate,  iodide  of  potassium,  and  similar  remedies. 

CANCER  OP  THE  PANCREAS.— Much  more  is  known  in  regard 
to  this  than  to  any  other  affection  of  the  pancreas.  The  ordinary 
form  of  cancer  affecting  this  organ  is  scu'rhus,  and  scirrhus  character- 
ized by  a  denser  stroma.  Medullary  and  colloid  have  also  appeared  in 
the  pancreas,  but  very  rarely.  Scirrhus  of  the  pancreas '  is  more  fre- 
quently secondary  than  primary,  and  even  as  a  secondary  disease  it 
is  very  rare,  occurring  in  cancer  cases  in  the  proportion  of  about  six 
per  cent.  only.  It  develops  most  frequently  in  the  head  of  the  pan- 
creas and  occurs  there  as  a  secondary  disease,  and  extends  thence  over 
the  body  of  the  organ.  It  is  more  frequently  confined  to  the  head 
than  to  other  parts  of  the  organ  ;  in  200  cases  there  were  33  in  which 
the  disease  was  confined  to  the  head,  and  in  88  the  whole  organ  was  af- 
fected.* A  tumor  of  the  pancreas  of  considerable  size  must  impinge  on 
neighboring  organs  ;  it  may  compress  the  ascending  vena  cava,  causing 

*  Ancelet,  "  Etudes  sur  les  Maladies  du  Pancreas,"  Paris,  1866,  p.  34. 


CANCER   OF   THE   PANCREAS.  139 

oedema  of  tlie  lower  extremities  ;  the  ductus  communis  choledochus 
causing  jaundice,  the  pancreatic  duct,  causing  dilatation  and  the  for- 
mation of  concretions,  the  ureter  causing  hydronephrosis,  and  the 
duodenum  causing  stenosis  and  dilatation  of  the  bowel  above  and 
subsequently  of  the  stomach.  It  is  usual  for  cancer  of  the  pancreas 
to  extend  to  and  implicate  other  organs,  which  may  be  bound  down 
into  a  uniform  mass,  in  which  the  point  of  initial  dej^osition  may  not 
be  distinguishable.  The  duodenum,  the  stomach,  the  gall-bladder,  the 
kidney,  the  liver,  mesenteric  glands,  and  peritoneum  may  all  be  in- 
cluded in  a  mass  of  which  the  beginning  was  in  the  head  of  the  pan- 
creas. Ulcerations  into  neighboring  organs  may  also  take  place — as 
into  the  stomach,  duodenum,  vena  cava,  portal  vein,  splenic  artery,  etc. 
Cancer  of  the  pancreas  is  more  frequent  in  males  than  in  females  ; 
in  Dr.  Da  Costa's  *  cases  there  were  24  males  and  13  females  ;  nearly 
twice  as  frequent,  which  is  the  proportion  noted  by  other  observers. 
As  is  the  rule  with  scirrhus  in  all  situations,  the  morbid  growth  makes 
its  appearance  from  forty  to  sixty  years  of  age.  Pain  is  an  early  symp- 
tom, and,  as  it  appears  without  cause,  is  persistent  and  rather  increases 
than  diminishes,  and  as  progressive  emaciation  and  feebleness  accom- 
pany it,  esjDecially  if  the  age  of  the  subject  be  suitable,  it  is  extremely 
suggestive  of  malignant  disease.  The  pain  is  situated  in  the  epigastric 
region  and  radiates  through  the  numerous  ramifications  of  the  solar 
plexus,  into  the  back,  through  the  abdomen  ;  it  is  pretty  constant,  with 
paroxysms  of  great  severity  in  which  the  suffering  is  agonizing  ;  it  is 
increased  by  the  erect  posture,  and  is  relieved  by  bending  the  body 
forward.  The  presence  of  a  tumor  has  a  high  degree  of  importance, 
but  it  is  not  always  found,  and  when  discovered  may  be  misleading. 
A  tumor  is  discovered  in  not  more  than  one  third  of  the  cases,  owing 
to  the  depth  at  which  the  pancreas  lies.  The  head  of  the  pancreas 
has  been  often  mistaken  for  scirrhus.  If  enlarged  lymphatics  be  felt, 
and  especially  if  the  cervical  lymphatics  are  enlarged,  support  will 
be  given  to  the  supposition  that  an  existing  tumor  is  malignant.  In 
a  small  proportion  of  cases,  an  excess  of  fat  in  the  stools  is  a  symp- 
tom which  throws  light  on  the  case.  The  appearance  of  jaundice, 
the  passage  of  blood  by  stool,  oedema  of  the  lower  extremities,  and 
disorders  of  digestion,  are  coincident  with  the  extension  of  the  new 
growth  to  neighboring  organs,  and  rather  confuse  than  clear  up  the 
diagnosis.  In  Da  Costa's  37  cases,  jaundice  was  present  in  24,  dyspep- 
sia in  25,  dropsy  (anasarca  or  ascites)  in  15.  "With  the  development  of 
these  symptoms  there  is  a  corresponding  increase  in  the  gravity  of  the 
constitutional  state.  The  general  condition  and  the  cachexia,  such  as 
have  been  described  as  belonging  to  cancer  of  the  stomach,  are  present 
in  these  cases.    The  duration  varies  somewhat.    The  most  severe  termi- 

*  "N.  A.  Med.  Chirurg.  Review,"  September,  1858,  p.  883. 


140  DISEASES   OF   THE   LIVER. 

nate  in  a  few  months,  and  but  rarely  is  any  case  protracted  beyond  a 
year.  The  rate  of  progress  is  influenced  by  the  complications — by  the 
pressure  on  neighboring  organs  and  interference  with  their  functions. 
Sudden  death  may  be  due  to  erosion  of  a  large  vessel. 

CYSTS  OP  THE  PANCREAS Chronic  interstitial  pancreatitis  is 

the  chief  factor  in  their  causation,  as  in  the  production  of  the  corre- 
sponding cysts  of  the  kidney.  Ducts  being  obstructed  by  the  growth 
of  the  connective  tissue  (hyperplasia),  the  contents  of  the  acini — the 
secretion — accumulate,  the  walls  yield  to  the  increasing  pressure,  and 
thus  a  cyst  is  formed.  Hasmorrhage  into  such  cysts,  purulent  trans- 
formation, and  albuminoid  degeneration,  effect  important  changes  in 
the  contents  of  these  cysts.  Obstruction  of  the  duct  of  Wirsung  by 
a  calculus,  by  neoplasms,  by  cancer  of  the  duodenum  and  tumors,  will 
cause  a  cystic  degeneration  of  the  whole  gland. 

CALCULI  OP  THE  PANCREAS.— These  are  concretions,  consist- 
ing of  carbonate  and  phosphate  of  lime,  which  have  crystallized  about 
a  bit  of  inspissated  mucus  or  other  organic  matter.  To  produce  them 
there  must  be  a  catarrhal  state  of  the  mucous  lining  of  the  ducts,  a 
change  in  the  secretion  toward  an  excess  of  its  earthy  constituents,  or 
an  obstruction  leading  to  retention  of  the  secretion.  The  pancreas  is 
also  liable  to  amyloid  and  fatty  degeneration,  and  is  sometimes  the 
seat  of  secondary  tubercular  deposits.  The  diseases  of  this  organ  are, 
however,  chiefly  of  pathological  interest. 


DISEASES    OF    THE    LIYER. 


CONGESTION    OP    THE    LIVER. 

Definition. — By  congestion  of  the  liver  is  meant  an  increase  in  the 
amount  of  blood  in  the  organ.  Owing  to  the  mechanical  arrangement 
of  its  vessels,  the  circulation  in  the  liver  is  influenced  by  the  condition 
of  the  heart  and  lungs,  by  the  state  of  digestion,  and  by  the  action  of 
the  diaphragm  and  abdominal  muscles.  It  is  therefore  peculiarly 
liable  to  suffer  from  changes  in  its  blood-supply.  It  may  be  active 
(malaria,  excesses  in  eating),  or  passive  (mechanical  stasis  from  ob- 
struction at  the  heart  or  lungs). 

*  Forster,  "  Lehrbuch  dcr  pathologischen  Anatomie,"  Jena,  1873,  p.  257. 


CONGESTION   OF   THE   LIVER.  141 

Causes. — The  increased  fullness  of  the  portal  vein  and  hepatic  ar- 
tery during  the  process  of  digestion  is  a  physiological  state,  which 
becomes  pathological  when  excesses  in  eating  and  drinking  are  habitu- 
ally committed.  The  admission  of  irritating  substances  to  the  blood, 
as  alcohol,  highly  stimulating  condiments,  the  salts  of  lead,  phosphorus, 
etc.,  increases  the  tendency  to  congestion.  In  malarious  regions,  con- 
gestion of  the  liver  is  produced  and  maintained  by  the  absorption  of 
malaria,  especially  when  in  sufficient  quantity  to  cause  febrile  attacks. 
Without  the  objective  evidence  of  malarial  infection  afforded  by  fever, 
the  spleen  may  greatly  enlarge  (ague-cake),  and  the  liver  be  kept  ab- 
normally full  of  blood. 

Obstruction  and  regurgitation  of  the  mitral  orifice  and  of  the  right 
cavities  induce  abnormal  fullness  of  the  venous  system,  and  ischaemia 
of  the  arteries.  After  the  lungs,  the  liver  is  the  first  organ  to  suffer 
the  passive  congestion  thus  caused.  The  same  result  is  produced  when 
an  obstructive  disease  of  the  lungs  maintains  congestion  on  the  venous, 
and  ischoemia  on  the  arterial  side  of  the  systemic  circulation. 

A  state  of  the  nervous  system  may  affect  the  circulation  in  the 
liver  to  a  great  extent  :  injury  of  the  semi-lunar  ganglion  causes  im- 
mense congestion  (Frerichs).  Section  of  splanchnic  nerves  and  the 
action  of  curare  and  some  other  poisons  have  the  same  effect.  A  fit  of 
anger  has  brought  on  an  attack  of  jaundice.  Indeed,  the  facts  prove 
that  the  nervous  system,  probably  through  the  vaso-motor  nerves,  ex- 
ercises an  immediate  influence  over  the  circulation  of  the  liver,  the 
mechanism  consisting  in  an  increased  or  diminished  blood-supply,  by 
paresis  or  spasm — by  the  action  of  the  dilator  or  constricting  fibers 
of  this  system. 

Congestion  may  also  occur  in  consequence  of  sudden  arrest  of  an 
habitual  discharge,  and  has  followed  a  successful  operation  for  htemor- 
rhoids.* 

Pathological  Anatomy. — When  the  congestion  is  the  result  of 
mechanical  obstruction  at  the  heart  or  lungs,  the  changes  which  are 
entitled  "  the  nutmeg-liver  "  are  seen  on  section  of  the  organ.  At  the 
center  of  each  lobule  the  dilated  radicle  of  the  hepatic  vein,  enlarged 
and  congested,  may  be  discerned,  while  the  neighboring  parts  of  the 
lobule  are  pale,  and  the  radicles  of  the  portal  are  by  comparison  less 
full  of  blood,  and  really  contain  less  because  of  the  increased  pressure 
from  dilatation  of  the  central  vein.  On  section,  a  greater  quantity  of 
venous  blood  flows  out  than  is  normal,  and  the  whole  organ  is  darker 
and  larger.  The  hepatic  cells  are  either  normal  or  present  in  places, 
some  cloudiness  from  albuminous  infiltration,  commencing  fatty  de- 
generation, and  some  brown-pigment  deposition  (Forster).  The  com- 
pression exercised  upon  the  hepatic  ducts  interferes  with  the  discharge 

*  Murchison,  "Diseases  of  the  Liver,"  1877,  p.  134. 


142  DISEASES   OF   THE   LIVER. 

of  bile  ;  and  staining  of  the  lobules  about  the  eenti'al  vein  is  a  result, 
causing  that  appearance  known  as  "  hepatic  icterus."  The  consistence 
of  the  liver  is  augmented  by  the  congestion  if  it  continue  for  a  length- 
ened period.  The  bile  is  not  changed  in  its  composition  (Frerichs), 
A  catarrhal  state  of  the  ducts  is  set  up  as  a  consequence  of  the  con- 
gestion, and  in  due  course  hypereemia  of  the  portal  radicles  of  the 
gastro-intestinal  canal  takes  place,  and  a  catarrh  of  the  mucous  mem- 
brane results. 

Long-continued  hyperaemia  of  the  liver  establishes  a  slow  atrophic 
degeneration  of  the  organ,  consisting  in  wasting  and  disappearance  of 
those  cells  lying  in  contact  with  the  dilated  central  vein,  their  places 
being  supplied  by  connective  tissue  having  a  granular  appearance. 
The  disappearance  of  these  cells  and  the  contraction  of  the  newly 
formed  connective  tissue  cause  a  diminution  in  the  size  of  the  liver, 
and  an  increase  of  its  density,  so  that  this  state  is  often  confounded 
with  cirrhosis  ;  but  the  substance  of  the  organ  has  not  the  density, 
nor  are  there  present  the  prominences  which  give  the  nodular  aspect 
to  the  latter. 

Symptoms. — Acute  congestion  of  the  liver  usually  begins  with  a 
general  malaise  /  aching  in  the  limbs  and  back ;  some  slight  rise  of 
temperature  toward  evening  ;  headache  ;  a  coated,  yellowish  tongue  ; 
loss  of  appetite,  even  repugnance  to  eating  ;  nausea.  More  or  less  un- 
easiness, usually  a  feeling  of  weight  and  of  tension,  and  tenderness, 
are  experienced  over  the  hypochondrium  ;  lying  on  the  left  side  causes 
a  veiy  unpleasant  sensation  of  weight  and  dragging  ;  buttoning  of  the 
clothing  can  not  be  borne  ;  and  the  easiest  position  is  recumbent,  with 
the  decubitus  toward  the  right  lateral  plane,  so  that  the  congested 
organ  can  be  well  supported  against  the  ribs.  On  the  other  hand, 
many  patients  seek  a  different  position  and  can  not  bear  any  pressure 
against  the  hypochondrium.  On  percussion,  the  area  of  heijatic  dull- 
ness is  enlarged  in  all  directions.  In  the  normal  state  the  upper  bor- 
der of  the  liver  is  parallel  with  the  lower  border  of  the  sixth  rib  on 
the  mammillary  line — in  ordinary  quiet  breathing  ;  on  full  expiration 
the  liver  rises  on  a  line  parallel  to  the  fifth  rib,  and  on  full  inspiration 
it  falls  to  the  seventh.  The  lower  border  of  the  liver  in  health  cor- 
responds to  the  inferior  margin  of  the  ribs,  or  extends  a  finger's 
breadth  below.  If  the  liver  is  enlarged  by  hyperaemia,  the  hepatic 
dullness  will  extend  across  the  epigastrium  to  the  left  hypochondrium. 
It  is  highly  important  to  note  that  the  area  of  dullness  does  not  rejare- 
sent  the  actual  size  of  the  organ,  for  the  thin  margins  do  not  return  a 
dull  sound  on  percussion.  Especially  will  misconception  occur  on  this 
point  when  the  ascending  colon  is  distended  with  gas.  Again,  the 
area  of  hepatic  dullness  may  be  greatly  enlarged  downward  by  altera- 
tions in  the  form  and  shape  of  the  liver,  when  congenital,  produced  by 
tight  lacing,  etc.,  or  displaced  downward  by  effusion  in  the  thorax,  tu- 


CONGESTION   OF   THE   LIVER.  143 

mors,  etc.  Although  percussion  affords  the  most  certain  physical  evi- 
dence of  enlargement  of  the  liver,  inspection  may  afford  some  assist- 
ance in  making  a  diagnosis,  as  by  the  eye  an  enlargement  of  the  hepatic 
space  may  be  discerned.  By  palpation,  the  liver  may  be  felt  project- 
ing below  the  ribs,  and  its  smoothness  or  nodulation,  its  density  and 
resistance,  may  be  readily  determined.  By  mensuration,  the  diameter 
of  the  two  sides  may  be  compared,  when  it  will  be  found,  if  the  con- 
gestion is  considerable,  and  the  atrophic  change  has  not  occurred,  that 
the  right  is  enlarged.  A  very  characteristic  symptom  in  these  cases  is 
a  light  grade  of  jaundice.  If  there  be  no  recognizable  tinting  of  the 
skin,  the  sclerotic  will  be  distinctly  yellow,  and  the  complexion  will 
have  the  so-called  "  muddy  "  aspect.  The  integument  in  the  cardiac 
liver  is  somewhat  earthy,  faintly  yellow,  or  fawn-color,  as  in  various 
cachexise.  In  the  acute  congestion  due  to  temperature  changes,  to 
malarial  infection,  to  excesses  in  eating  and  drinking,  etc.,  there  is 
usually  some  gastro-duodenal  catarrh,  and  catarrh  of  the  bile-ducts, 
and  consequently  an  obstacle  to  the  outflow  of  bile,  with  more  or  less 
intense  icterus.  The  urine  in  every  case  contains  some  pigment,  and 
varies  in  tint  from  pale  sherry  to  a  port-wine  color,  and  casts  an  abun- 
dant deposit  of  urates  with  much  pigment  matter.  In  the  more  severe 
cases  there  is  considerable  gastric  disturbance,  and  vomiting  of  bile, 
and  large,  so-called  biliou.s  discharges  take  place  by  the  bowels.  The 
stools,  after  the  ordinary  fecal  evacuations,  consist  of  a  greenish-yel- 
low or  brownish  matter,  semi-fluid  or  thinner  greenish  or  yellowish 
liquid  having  the  appearance  and  consistence  of  stored-up  bile.  Some- 
times a  large  quantity  of  such  material  is  discharged,  giving  great  re- 
lief, the  pain,  soreness,  and  heaviness  in  the  side  and  the  headache  and 
feverishness  disappearing.  Such  acute  cases  are  due  to  climatic,  mala- 
rial, or  dietetic  causes.  In  the  cases  of  congestion  due  to  cardiac  dis- 
eases or  j)ulmonary  obstruction,  the  symptoms  of  hepatic  congestion 
come  on  slowly  ;  there  occur  a  gradual  tension  and  weight  in  the  right 
hypochondrium,  a  slow  increase  in  the  size  of  the  liver,  an  enlargement 
of  the  area  of  hepatic  dullness,  and,  usually,  a  very  slight  appearance 
of  icterus,  combined  with  more  or  less  cyanosis,  producing  a  violet-yel- 
low or  greenish  coloration.  Often,  in  protracted  examples  of  this  form 
of  congestion,  there  exists  extensive  gastro-intestinal  catarrh,  with  dis- 
turbed digestion,  nausea,  vomiting,  diarrhoea,  etc.  In  those  cases  of 
congestion  of  the  liver  due  to  psychical  impressions,  jaundice  is  the 
main  symptom  ;  there  exists  really  a  congestion  in  biliary  production, 
with  more  or  less  hyperemia,  but  there  is  no  marked  enlargement, 
tenderness,  or  heaviness  in  the  hepatic  area,  and  the  patients  experi- 
ence the  sensations  belonging  to  an  intense  icterus,  consisting  of  itch- 
ing of  the  surface,  depressed  spirits,  slow  action  of  the  heart,  muddy 
urine,  and  a  general  yellowness  or  jaundice. 

Course,  Duration,  and  Termination. — The  subsequent  behavior  of 


144  DISRASES    OF   THE    LIVER. 

cases  of  hepatic  congestion  offers  wider  differences  than  exist  in  the 
clinical  history.  The  cases  of  congestion  due  to  obstructive  diseases 
of  the  heart  or  lungs  develop  slowly  and  continue  indefinitely,  and 
their  course  and  duration  are  those  of  the  cardiac  or  pulmonary  dis- 
ease. In  these  cases  important  alterations  occur  in  the  liver  ulti- 
mately ;  it  undergoes  atrophy,  obstruction  to  the  portal  circulation  is 
added  to  the  stasis  in  the  general  venous  system,  and  ascites  slowly 
forms.  In  the  acute  cases  due  to  climatic  and  hygienic  causes,  the 
course  is  short,  but  the  symptoms  are  violent.  The  whole  duration 
of  such  an  attack  will  not  be  more  than  a  week  or  ten  days,  and  the 
termination  is  in  health.  The  same  causes  which  produce  the  attack 
will  operate  in  the  future,  and  other  attacks  will  succeed,  and  ulti- 
mately, in  some  cases,  chronic  disease  of  the  liver  will  be  established  ; 
but,  if  the  causes  cease,  the  effects  will  also.  In  the  nervous  cases, 
the  jaundice  reaches  its  maximum  in  a  few  hours,  and  then  begins 
to  decline,  and  usually  lasts  four  or  five  days,  terminating  in  re- 
covery. 

Diagnosis. — The  acute  form  of  congestion  may  be  confounded  with 
jaundice  from  catarrh  of  the  bile-ducts,  the  symptoms  being  much  the 
same  ;  but  the  duration  of  the  cases  differs,  and  the  latter  is  preceded  by 
symptoms  of  gastro-duodenal  catarrh,  while  in  the  former  these  symp- 
toms succeed  to  the  disturbance  in  the  hepatic  functions.  The  conges- 
tion due  to  obstructive  pulmonary  or  cardiac  disease  is  diagnosticated 
b^  its  clinical  history  and  the  association  of  the  two  groups  of  lesions. 
The  contraction  of  the  liver,  which  succeeds  to  enlargement  in  the 
cases  of  nutmeg-liver,  may  be  confounded  with  cirrhosis  ;  but,  as  these 
states  have  been  confounded  by  pathologists,  the  differentiation  is  not 
important  from  the  clinical  standpoint. 

Treatment. — The  treatment  of  the  cases  due  to  pulmonary  or  car- 
diac obstruction  is  a  question  of  the  management  of  the  lesions,  cardiac 
or  pulmonary,  as  the  case  may  be.  Not  unfrequently,  before  the  heart 
and  lungs  are  incommoded  in  mitral  disease,  the  hepatic  functions  are 
so  disturbed  as  to  demand  attention.  The  timely  prescription  of  digi- 
talis may  afford  relief,  not  given  by  the  remedies  for  disorder  of  the 
liver.  As  the  condition  is  one  of  abnormal  fullness  of  the  venous  sys- 
tem of  the  liver,  relief  is  afforded  in  those  of  full  habit  by  leeches 
around  the  anus.  Unfortunately  the  need  for  digitalis,  to  diminish  the 
leak  at  the  miti-al  and  for  leeches  to  unload  the  distended  veins,  con- 
tinues. Free  wateiy  evacuations,  produced  by  salines,  are  highly  use- 
ful ;  but  in  the  progress  of  this  disease  the  congestion  of  the  mucous 
membrane  excites  a  catarrh  and  diarrhoea,  so  that  the  limit  of  utility 
by  saline  purgatives  is  soon  reached.  In  the  acute  congestion  due  to 
climatic  or  malarial  causes,  no  remedy  is  so  efiicient  as  a  full  dose  of 
quinia  (grs.  xv — 3j)  with  morphia  (gr.  ^ — |).  Small  doses  frequently 
repeated  may,  if  preferred,  be  employed,  but  the  large  dose  is  more 


SCLEROSIS    OF   THE    LIVER.  145 

efficient.  A  mild  saline  laxative,  to  keep  the  bowels  soluble  (the  Sara- 
toga waters  may  be  used),  is  necessary,  and  elimination  by  the  kidneys 
should  be  maintained  by  the  use  of  lemonade  and  diluents.  Fomen- 
tations, turpentine-stupes,  etc.,  applied  to  the  hepatic  region  are  ser- 
viceable. When  the  attacks  are  due  to  errors  of  diet,  spirituous  liquors, 
and  similar  abuses,  there  must  be  a  change  in  the  habits  of  the  indi- 
vidual. Abstinence,  the  use  of  a  laxative,  and  quiet,  will  effect  a  cure, 
provided  the  excesses  have  been  recent,  and  alterations  of  structure 
have  not  occurred  in  the  liver. 


INTERSTITIAIi    HEPATITIS  —  SCLEROSIS    OF    THE    LIVER— CIR- 
RHOSIS. 

Definition. — By  the  term  interstitial  hepatitis  is  meant  an  inflam- 
mation of  the  intervening  connective  tissue.  An  induration  of  the 
organ  is  the  result  of  this  process,  and  hence  it  is  entitled  sclerosis, 
just  as  this  term  is  used  for  corresponding  states  of  other  organs — as 
sclerosis  of  the  kidney,  sclerosis  of  the  lungs,  etc.  Cirrhosis  is  the 
French  term  derived  from  the  Greek  word  hirros  (red),  so  named  on 
account  of  the  color  of  the  liver.  As  a  very  inappropriate  designation, 
it  should  cease  to  be  used. 

Causes. — This  is  a  disease  of  adult  life,  and  rarely  occurs  before  the 
period  of  puberty,  chiefly  because  the  conditions  are  wanting  at  this 
time.  Griffith  reports  a  case  in  a  child  of  ten  ;  Cayley,  in  another  child 
of  six  ;  and  Murchison,  in  a  boy  of  ten.  Nothing  definite  as  regards 
the  cause  was  known  in  the  first  two,  notwithstanding  a  searching  in- 
vestigation ;  in  the  other,  the  abuse  of  spirits,  medicinally  and  other- 
wise, was  ascertained.*  Murchison  has  never  met  with  an  example  of 
hob-nailed  liver  in  which  excess  in  the  use  of  spirits  had  not  been  made 
out.  There  can  lae  no  doubt  that  the  male  sex  is  more  frequently  at- 
tacked than  the  female,  not  because  there  exists  any  inaptitude  in  the 
latter,  but  because  of  the  difference  in  habits.  The  great  factor  is  the 
free  use  of  alcoholic  liquors.  The  amount  which  constitutes  excess 
differs  in  different  individuals  ;  in  some  subjects  a  small  amount  of 
alcohol,  daily,  suffices  to  set  up  the  interstitial  inflammation,  when  an- 
other person  would  not  be  affected  by  it  in  any  way.  It  is  highly 
probable  that  hereditary  syphilis  is  a  cause,  but  there  are  obvious  dif- 
ficulties in  the  way  of  a  correct  determination  of  this  point.  The  form 
of  atrophy  which  succeeds  to  the  chronic  stasis  of  the  liver  in  obstruc- 
tive cardiac  disease  is  often  confounded  with  sclerosis  proper,  but  the 
change  begins  by  an  atrophy  of  the  hepatic  cells  next  the  intra-lobular 
vein  in  the  former  ;  whereas,  in  the  latter,  the  atrophy  begins  in  the 
peripheral  cells. 

*  "Transactions  of  the  Pathological  Society,"  vol.  xxvii,  1876,  pp.  186,  194,  199. 
10 


146  DISEASES  OF   THE  LIVER. 

Sclerosis  has  been  observed  to  follow  impaction  by  gall-stones  and. 
the  paludal  cachexia. 

Pathological  Anatomy. — In  the  first  stage,  the  organ  is  somewhat 
increased  in  size  and  hypersemic  ;  its  parenchyma  is  somewhat  denser, 
by  reason  of  the  presence  of  a  viscid,  reddish-gray  material,  which 
consists  of  fine  connective-tissue  elements,  containing  spindle-shaped 
cells  (Forster).*  The  development  of  this  material  imparts  to  the  par- 
enchyma a  granular  aspect.  The  color  of  the  organ  is  at  this  period  a 
brownish-red,  whence  the  name  cirrhosis,  or  it  may  be  greenish  by 
staining  of  the  bile -pigment ;  or  the  deposition  of  fat  may  give  it  a 
pallid  ajDpearance.  Thus  far,  there  is  an  actual  addition  of  material  to 
the  organ,  and  it  is  somewhat  increased  in  size.  The  next  step  con- 
sists in  the  contraction  of  the  new  connective  tissue  and  induration. 
The  substance  of  the  liver  is  distinctly  harder,  and,  on  section,  the 
knife  is  resisted  as  if  passing  through  fibrous  tissue.  The  surface  of 
the  organ  is  unequal,  nodulated,  and  traversed  by  distinct,  thickened 
bands  of  connective  tissue  (whence  the  English  term  "hob-nailed"). 
The  line  of  section  presents  a  granular  appearance,  due  to  the  contract- 
ing of  the  intervening  connective-tissue  elements,  and  the  consequent 
forced  elevation  of  the  softer  material  of  the  lobules.  The  peritoneum 
is  opaque,  thickened  by  organized  exudation,  the  results  of  local  peri- 
tonitis, and  adhesions  are  formed  to  the  diai^hragm,  between  the  liver 
and  gall-bladder,  etc.  The  apj)earance  of  the  hepatic  tissue  is  due  to 
a  hyperplasia  of  the  connective  tissue  (Glisson's  capsule)  surrounding 
and  compressing  the  groups  of  cells.  The  cells  themselves,  where  the 
growth  of  connective  tissue  is  sufficient  to  compress  them,  undergo  a 
change  partly  fatty,  partly  pigmented,  and  in  some  places  amyloid. 
The  abnormal  pigmentation  is  due  to  compression  of  the  terminal 
ducts  and  stasis  of  the  bile.  The  vessels  of  the  liver  are  variously 
damaged.  In  those  parts  where  the  greatest  destruction  of  cells  has 
occurred,  the  radicles  of  the  portal  vein  are  obstructed,  and  the  radi- 
cles of  the  sub-hepatic  are  also  closed  by  compression  and  lose  their 
connection  with  the  capillaries  of  the  portal.  The  hepatic  artery  be- 
comes dilated,  and  supplies  the  newly  formed  vessels  of  the  recently 
developed  connective  tissue. f  The  important  alterations  occurring  in 
the  liver  lead  to  secondary  disorders  of  a  serious  kind.  The  interrup- 
tion to  the  circulation  by  closure  and  obliteration  of  many  of  the  he- 
patic capillaries — portal  and  hepatic — necessarily  causes  stasis  in  the 
whole  range  of  the  portal  system,  including  the  chylopoietic  viscera. 
The  formation  of  bile  is  impaired,  diminished,  and  at  many  points  en- 
tirely su]3pressed.    The  glycogenic  and  urea-forming  functions  are  dis- 

*  Op.  cit.,  p.  264. 

■j-  Cornil,  "  Note  sur  I'etat  anatomique  des  canaux  biliaires  et  des  vaisseaux  sanguins 
dans  la  cirrhose  du  foie,"  "  Bull,  de  I'Acad.  de  Med.,"  "  Gaz.  Med.  de  Paris,"  1873. 


SCLEROSIS   OF   THE   LIYER.  147 

ordered  to  the  some  extent  ;  consequently  the  depuration  of  the  blood 
and  the  function  of  digestion,  in  so  far  as  the  presence  of  bile  is  neces- 
sary to  the  latter,  ai'e  hindered  or  prevented. 

Symptoms. — The  initial  symptoms  are  those  of  congestion — some 
heaviness,  and  dragging  in  the  right  side,  and  increase  in  volume,  the 
liver  projecting  a  finger's  breadth  below  the  ribs.  There  will  be  pres- 
ent, usually,  some  pain  and  tenderness  on  pressure,  and  now  and  then 
acute  pain  with  a  febrile  movement  indicative  of  local  peritonitis.  A 
slight  icterode  hue  of  the  skin  may  also  appear,  and  rarely  jaundice. 
Again,  in  other  cases,  before  symptoms  referable  to  the  liver  mani- 
fest themselves,  gastro-intestinal  disorders — gastro-intestinal  catarrh — 
occur.  The  appetite  is  poor,  and  food  occasions  distress  ;  there  is 
acidity,  and  acid  matters  are  regurgitated  :  often  in  the  morning  there 
are  much  nausea  and  great  straining,  seme  acid,  glairy  mucus  and  bil- 
ious matter  coming  up  after  much  effort.  The  bowels  are  sometimes 
relaxed,  sometimes  constipated,  and  now  and  then  blackish,  tar-like, 
semi-solid  discharges  occur.  As  intestinal  hyperasmia  is  always  pres- 
ent, and  sero-mucus  constantly  poured  out,  diarrhoea  soon  comes  to  be 
the  usual  condition.  A  troublesome  meteorism  is  a  constant  symptom, 
and  this  is  due  to  decomposition  of  certain  foods  and  a  paretic  state 
of  the  bowels.  There  are  also  cases,  but  rarely,  in  which  the  devel- 
opment of  sclerosis  takes  place  silently,  and  the  first  symptom  to 
awaken  attention  is  ascites.  As  respects  size,  the  liver  usually  enlarges 
at  first,  but  contraction  soon  comes  on,  and  a  considerable  reduction 
takes  place,  the  area  of  hepatic  dullness  being  correspondingly  re- 
duced. There  are  cases,  however,  in  which  the  sclerosis  takes  place 
while  the  organ  continues  enlarged — a  condition  known  as  hypertro- 
phic Gclerosis.  As  the  splenic  forms  a  part  of  the  portal  system  of 
veins,  a  constant  stasis  is  maintained  in  the  circulation  of  the  spleen, 
and  hence  this  organ  remains  swollen  ;  but  there  are  variations  in  its 
size,  due  to  the  fonnation  of  a  collateral  circulation,  and  occasionally 
to  the  development  of  a  sclerosis  in  the  organ.  A  constant  stasis  is 
also  maintained  in  the  intestinal  mucous  membrane,  with  the  results 
already  mentioned.  An  attempt  at  compensation  for  the  obstruction 
in  the  venous  system  of  the  abdomen  is  made  by  enlargement  of  cer- 
tain communicating  veins,  which  in  health  are  but  slightly  auxiliary 
to  the  regular  route  of  communication.  On  the  surface  of  the  abdo- 
men, from  the  xiphoid  appendix  to  the  pubis,  veins  appear,  which  were 
previously  invisible  ;  they  are  the  communicating  veinules  between 
the  epigastric  and  internal  mammary,  forming  an  irregulai',  feather- 
shaped  figure  ;  interlacing  vessels  also  form  along  the  rectus  muscle, 
laterally  ;  communication  is  established  between  the  parietal  veins  and 
the  accessory  vena  porta  of  Sappey,  and  those  branches  of  this  acces- 
sory portal,  communicating  with  the  epigastric  and  internal  mammary 
veins,  foi-m  a  cushion,  bluish  in  color,  of  distended  vessels  around  the 


14S  DISEASES   OF   THE   LIVER. 

umbilicus  (caput  Medusae)  :  communication  also  takes  place  between 
the  inferior  mesenteric  and  the  hypogastric  veins,  through  the  hsemor- 
rhoidal,  and  between  the  anastomoses  of  the  portal  with  the  oesopha- 
geal and  diaphragmatic  veins. 

Haemorrhages  result  from  the  stasis — hsematemesis  or  vomiting  of 
blood,  and  intestinal  haemorrhage  ;  the  vessels  yield  under  the  in- 
creased pressure ;  or  thromboses  form  in  the  stomach-veins,  solution 
of  the  affected  mucous  membrane  occurs,  and  an  ulcer  is  the  result. 
The  author  has  seen  two  cases  of  cirrhosis  in  which  frequently  recur- 
ring hsematemesis  caused  death,  the  haemorrhage  coming  from  small 
ulcers  in  the  vicinity  of  the  pylorus.  The  black,  tar-like  stools  which 
are  passed  now  and  *then  in  contracted  liver  consist  of  blood  altered 
by  the  intestinal  juices.  The  same  obstruction  of  the  portal  circula- 
tion leads  to  tbe  formation  of  haemorrhoids,  which  often  bleed  freely 
and  thus  afford  relief.  Besides  the  interference  with  the  digestive 
function  due  to  the"gastro -intestinal  catarrh,  the  solution  and  absorj)- 
tion  of  certain  kinds  of  food  are  prevented  by  the  absence  of  the  bile. 
These  are  especially  the  fatty  and  saccharine  matters,  and  bile  has  the 
peculiar  property  of  aiding  the  absorption  of  fats.  Further,  it  plays 
the  part  of  an  antiseptic  agent,  and  prevents  the  decomposition  of  food 
in  the  small  intestine  :  when  bile  is  absent  the  faeces  are  not  only  want- 
ing in  the  proper  color,  but  they  have  a  peculiarly  fetid  odor — the  odor 
of  decomposition — and  the  gas  passed  has  the  same  foul  smell.  A 
gradual  emaciation  is  the  necessary  result  of  this  morbid  condition  of 
the  intestinal  digestion.  The  integument  of  .the  face,  neck,  and  fore- 
arms acquires  a  peculiar,  earthy,  icteroid  hue,  but  a  real  jaundice  is 
not  common  in  cases  of  sclerosis.  Sometimes  with  the  first  conges- 
tion, which  initiates  the  morbid  process,  jaundice  is  a  symptom,  but  it 
soon  disappears  and  the  earthy,  fawn  color,  so  characteristic  in  these 
cases,  gradually  develops.  In  those  cases  of  sclerosis  succeeding  to 
impaction  by  gall-stones,  jaundice  has  been  a  prominent  symptom. 
When  the  cells  have  atrophied,  and  the  canaliculi  are  obliterated,  re- 
sorption of  bile  is  no  longer  possible.  The  very  considerable  inter- 
ference with  the  process  of  digestion  produced  by  sclerosis  and  the 
retention  in  the  blood  of  those  effete  materials  which  it  is  the  func- 
tion of  the  liver  to  remove  induce  an  unhealthy  condition  of  that 
fluid,  and  hence  venous  stigmata  appear  on  the  face  and  nose,  and 
bleeding  occurs  from  the  nose,  lungs,  peritoneum  (peritonitis  haemor- 
rhagica),  and  elsewhere.*  The  urine  is  small  in  quantity,  high  colored, 
brownish,  deficient  in  urea,  but  loaded  with  urates  which  are  deposited 
in  great  abundance  along  with  much  coloring  matter.  Q^^dema  of  the 
feet  and  ankles  succeeds  to  ascites,  and  the  genitalia  become  much 
swollen.  But  the  clinical  history  and  treatment  of  ascites  have  been 
sufficiently  discussed. 

*  "Thfese  de  Paris,"  1814:,  Azmi  Ahmed,  "Des  heraorrhagies  dans  la  cirrhose." 


SCLEROSIS   OF   THE,  LIVER.  149 

Course,  Duration,  and  Termination. — The  course  of  interstitial  hepa- 
titis is  essentially  chronic.  The  first  stage,  or  period  of  congestion 
and  enlargement,  often  escapes  notice,  and  only  the  stage  of  contrac- 
tion, with  its  accompanying  accidents,  comes  under  observation.  The 
duration  is  not  fixed,  and  the  termination  is  governed  by  the  extent 
of  the  contraction  and  the  consequent  interference  with  function, 
but  especially  by  the  existence  or  appearance  of  such  complications  as 
mitral  disease,  emphysema  of  the  lungs,  and  chronic  interstitial  nephri- 
tis. Fibroid  change,  such  as  occurs  in  sclerosis  of  the  liver,  may  mani- 
fest itself  simultaneously  in  other  organs,  as  fibroid  lung,  fibroid  heart, 
fibroid  kidney.  Obviously,  the  course  and  duration  of  the  hepatic  dis- 
ease will  be  much  influenced  by  the  coexistence  of  this  form  of  degen- 
eration in  other  organs.  Toward  the  end  of  some  cases,  brain  symp- 
toms arise  which  were  at  one  time  supposed  to  have  the  same  relation 
to  retention  of  effete  products  removed  by  the  liver  in  the  normal  con- 
dition as  the  cerebral  symptoms  in  albuminuria  had  to  the  failure  of 
kidney  excretion.  By  Flint  this  toxic  material  is  supposed  to  be  cho- 
lesterine,  and  hence  the  term  cholestersemia  which  be  applies  to  these 
cerebral  symptoms.  This  condition  of  the  brain  takes  the  form  of 
stupor,  and  low-muttering  delirium,  passing  into  deep  coma.  In  a  few 
cases  sopor  and  gradually  deepening  stupor  come  on  early.  These 
mental  symptoms  are,  however,  mixed  up  with  the  perturbation  due 
to  alcoholic  excess,  so  that  it  is  impossible  to  assign  to  each  factor  its 
proper  influence  in  the  development  of  this  state.  A  large  proportion 
of  cases  end  before  these  mental  symptoms  are  reached,  cut  off  by  in- 
tercurrent maladies,  such  as  pleuritis,  pericarditis,  pneumonia,  etc.,  or 
die  exhausted  by  haemorrhage.  Some  cases  proceed  to  a  typical  end- 
ing by  gradual  failure,  worn  out  by  the  difficult  breathing  from  exces- 
sive accumulation  of  fluid,  the  constant  upright  position,  the  ulcerated 
legs,  the  bleeding  haemorrhoids,  repeated  tapping,  stupor,  delirium, 
and  gradually  deepening  coma. 

Diagnosis. — When  all  the  usual  symptoms  of  sclerosis  are  present, 
and  the  subject  of  them  has  been  given  to  alcoholic  intoxication,  there 
can  be  no  difficulty  in  coming  to  a  diagnosis  by  exclusion.  Further- 
more, sclerosis  is  greatly  more  frequent  than  any  of  the  diseases  with 
which  it  may  be  confounded.  The  difficulties  of  differentiation  occur 
with  pylephlebitis,  fatty  liver,  hydatid  cysts,  cancer  or  tuberculosis  of 
the  peritoneum.  In  pylephlebitis  or  inflammation  with  thrombosis  of 
the  portal  vein,  there  may  be  present  the  same  symptoms  as  in  sclero- 
sis, but  they  arise  suddenly,  and  are  not  preceded  by  the  symptoms  of 
congestion  and  a  history  of  alcoholic  abuse.  Fatty  liver  is  one  of  the 
complications  of  phthisis,  and  also  occurs  in  the  obese,  or  in  those  hav- 
ing the  tendency  to  obesity  and  who  eat  and  di-ink  freely  and.  lead  sed- 
entary lives.  Although  the  symptoms  referable  to  the  liver  are  similar 
to  those  which  are  present  in  sclerosis,  there  are  important  points  of 


150  DISEASES  OF   THE   LIVER. 

difference.  In  fatty  liver  emaciation  is  wanting  ;  the  organ  is  enlarged 
and  smooth,  instead  of  being  contracted  and  nodulated.  In  hydatid 
cyst,  there  is  a  slow,  gradual,  and  painless  enlargement,  with  but  little 
interference  in  the  function  of  the  liver,  and  without  the  secondary  gas- 
tro-intestinal  disorders.  On  palpation,  a  large,  soft,  elastic  growth  can 
be  made  out,  and  having  that  peculiar  symptom,  the  "purring  tre- 
mor." These  symptoms  are  all  wanting  in  sclerosis.  Cancer  differs 
from  sclerosis  in  that  the  pain  is  greater,  the  wasting  more  rapid,  the 
liver  presents  large  protuberances,  and  secondary  deposits  in  the  mes- 
entery can  be  felt  in  advanced  cases.  Cancer  and  tubercle  of  the  peri- 
toneum are  accompanied  by  symptoms  much  like  sclerosis.  They  may 
be  differentiated  by  attention  to  the  following  points  :  In  sclerosis, 
there  is  enlarged  spleen  ;  the  urine  is  deficient  in  urea  but  contains  leu- 
cin  and  tyrosin,  and  casts  an  abundant  deposit  of  urates  and  coloring 
matter  ;  in  cancer  or  tubercle,  the  spleen  is  not  enlarged  ;  the  urine 
contains  its  proper  proportion  of  urea,  and  is  pale  and  watery.  In  can- 
cer or  tubercle  of  the  peritoneum,  there  is  great  tenderness  of  the 
abdomen  ;  the  ascites  develops  quickly  ;  the  strength  and  flesh  rapidly 
decline,  and  there  are  usually  cancer  or  tubercle  deposits  in  other 
organs. 

Prognosis. — The  course  of  sclerosis  is  usually  continuously  down- 
ward, and  hence  the  prognosis  is  unfavorable.  The  author  believes 
that  the  opinions  as  to  its  incurability,  based  on  experience,  must  be 
somewhat  modified  now,  in  view  of  the  results  of  modern  treatment. 

Treatment. — At  the  outset  the  author  must  condemn  the  use  of 
mercurials  given  with  a  view  to  correct  the  hepatic  secretions.  The 
secretory  function  is  disturbed,  because  the  liver-cells  have  atrophied 
and  the  ducts  are  closed.  When  this  result  is  reached,  no  treatment 
can  modify  the  case,  for  remedies  can  not  restore  lost  parts.  Before 
important  changes  have  occurred,  although  new  connective  tissue  has 
formed,  and  some  contraction  has  taken  place,  the  author  believes  that 
much  may  be  done  to  arrest  the  morbid  process.  There  is  a  group  of 
remedies  which  have  a  selective  action  on  the  liver,  the  metals  chiefly: 
gold,  silver,  copper,  arsenic,  mercury,  and  phosphorus,  which  have  the 
property  of  improving  the  nutrition  of  the  liver  if  used  in  a  small 
quantity  for  a  long  period.  The  most  eflicient  of  these  are  the  chlorides 
of  gold  and  sodium,  the  corrosive  chloride  of  mercury.  Fowler's  solu- 
tion, and  phosphorus  in  the  form  of  phosphites  or  phosphates.  When 
there  is  much  irritability  of  the  gastro-intestinal  mucous  membrane,  two 
drops  of  Fowler's  solution,  with  two  to  five  drops  of  opium  tincture, 
three  times  a  day,  will  be  most  easily  borne.  If  there  is  less  imtabil- 
ity,  the  chloride  of  gold  and  sodium  (^^  gr.),  or  corrosive  chloride  of 
mercury  (^Jy  gr.),  ter  m  die,  can  be  administered.  No  good  result 
should  be  expected  unless  the  remedies  are  kept  up  for  several  months. 
The  author  has  seen  surprising  results  by  the  long-continued  use  of 


ABSCESS   OF   THE   LIVER.  151 

sodium  phosphate  in  these  cases — given  in  3j—  3  j  doses  three  times 
a  day.  The  good  effects  of  both  remedies  may  be  obtained  by  joint 
administration — the  phosphate  in  solution,  the  chloride  in  pill  form. 
When  it  is  considered  desirable  to  give  phosphates  and  arsenic  to- 
gether, phosphate  of  soda  and  arseniate  of  soda  may  be  combined.  If 
there  is  a  suspicion  of  syphilitic  taint,  the  iodides  of  potassium  and 
ammonium  and  the  bichloride  of  mercury  are  the  appropriate  medica- 
ments. The  mineral  acids,  which  at  one  time  were  supposed  to  be  effi- 
cacious in  the  treatment  of  this  hepatic  disorder,  are  now  rarely  em- 
ployed, except  to  facilitate  digestion.  The  nitro-muriatic  bath  is  a 
serviceable  topical  application,  especially  the  general  bath,  to  improve 
the  condition  of  the  skin,  which  is  dry,  harsh,  and  scurfy.  Attention 
to  the  diet  is  of  the  first  consequence.  Fats  and  saccharine  foods,  not 
undergoing  solution  and  absorption,  decompose  and  add  to  the  existing 
mischief.  The  continued  use  of  skimmed  milk  freely  is  a  dietectic 
measure  of  the  highest  importance.  Those  components  of  a  diet  con- 
vertible into  peptones  should  be  directed,  and  the  most  easily  digest- 
ed substances  only.  When  ascites  forms,  it  must  be  treated  according 
to  the  principles  already  set  forth  under  that  head  ;  the  activity  of  the 
kidneys  must  be  maintained,  and  puncture  practiced  according  to  ne- 
cessity. 

LOCAL    PARENCHYMATOUS  HEPATITIS— SUPPURATIVE    HEPA- 
TITIS—ABSCESS  OF  THE   LIVER. 

Definition. — The  hepatitis  which  terminates  in  suppuration  is  local- 
ixed  to  a  special  part,  and  the  rest  of  the  organ,  outside  the  area  of 
suppui-ation,  continues  comparatively  normal.  It  is  a  parenchymatous 
inflammation  in  that  the  proper  structure  of  the  organ — the  gland-cells — 
is  the  seat  of  the  inflammatory  process.  It  is  a  suppurative  hepatitis, 
in  that  the  tendency  is  to  the  formation  of  matter,  and  the  resulting  ab- 
scess is  the  special  feature  demanding  attention.  Murchison  makes  an 
appreciative  distinction  between  pyaemic  and  tropical  abscesses — the 
former,  a  result  of  blood-poisoning ;  the  latter,  caused  by  inflamma- 
tion of  the  liver.  It  is  the  latter  form  which  is  intended  by  the  term 
suppurative  hepatitis,  but  the  post-mortem  changes  and  the  clinical 
history,  so  far  as  the  liver  itself  is  concerned,  are  the  same  in  the  two 
forms. 

Causes. — External  injury  but  rarely  excites  suppurative  inflamma- 
tion, and  a  blow  on  the  right  hypochondrium  will  more  frequently 
cause  an  inflammation  of  the  hepatic  peritoneum  than  of  the  hepatic 
substance.  Blows  are  more  apt  to  cause  abscess  of  the  liver  in  warm 
than  in  cold  countries.     Climate  is  one  of  the  principal  factors.*     A 

*  Sachs,  "  Uebcr  die  Hepatitis  der  heissen  Lander,"  Berlin,  1876.  Separat-Abdruck 
aus  von  Laneenbeck's  "  Archiv,"  Band  xix. 


152  DISEASES   OF   THE   LIVER. 

warm  climate,  an  alluvial  soil,  and  miasmatic  influences,  are  more  influ- 
ential in  combination  than  climate  alone.  Abscess  of  the  liver  is  very 
common  in  the  great  interior  valley  of  North  America — along  the 
Mississippi  and  its  tributaries,  within  the  malarial  area — as  it  is  in 
India,  and  because  of  the  same  etiologic  and  climatic  conditions. 
Without  producing  the  objective  phenomena  of  fever,  malaria  dis- 
turbs the  hepatic  functions,  but  the  disturbance  is  still  more  decided 
when  the  poison  is  intense  enough  to  cause  fever.  Dysentery  and 
ulceration  of  the  intestines  have  so  frequently  coincided  in  appearance 
with,  or  have  preceded,  abscess  of  the  liver,  that  a  causal  relation  is  sup- 
posed by  many  to  exist  between  them.  In  the  interior  valley  of  this 
continent,  at  Cincinnati,  the  author  saw  many  cases  which  had  succeeded 
to  attacks  of  malarial  fever,  and  to  dysentery— especially  proctitis — the 
lesions  of  which  are  situated  chiefly  or  wholly  in  the  rectum.  Fre- 
richs,*  Murchison,f  and  some  other  systematic  writers,  after  a  thorougli 
examination,  maintain  the  opposite  view,  that  the  supposed  relation  be- 
tween abscess  of  the  liver  and  dysentery  is  merely  coincident,  and  is  not 
causal.  Waring's  |  statistics  seem  quite  conclusive  against  the  view  that 
such  a  relation  exists  :  thus,  "  out  of  2,758  cases  of  dysentery  treated 
in  the  Madras  Presidency,  abscess  of  the  liver  occurred  68  times,  being 
in  the  proportion  of  2^  per  cent,  nearly."  In  the  same  author's  300 
cases  of  abscess  of  the  liver,  "  hepatitis  was  the  j)rimary  affection  in 
131,  or  43  per  cent.,  while  only  82,  or  27  per  cent.,  were  admissions 
from  dysentery."  Budd  §  holds  that  a  poison  generated  in  the  intestine 
by  the  decomposition  of  materials  from  ulcerations  is  the  chief  factor 
in  the  causation  of  abscess.  Moxon  ||  also  maintains  that  "almost  all 
tropical  abscesses  are  secondary  to  dysenteric  or  other  ulcerations,  and 
that  primary  abscess  of  the  liver  is  at  least  as  doubtful  as  primary 
suppuration  of  the  brain."  The  concurrence  of  hepatic  abscess  and 
dysentery  is  too  frequent  not  to  be  related  in  some  way  ;  it  is  clear 
that  many,  but  probably  not  a  majority,  of  the  cases  thus  originate, 
and,  when  so  caused,  the  abscesses  are  pygemic,  multiple,  and  secondary. 
Large  abscesses  of  this  kind  are  due  to  the  coalescence  of  neighboring 
smaller  ones.  A  large  number  are  doubtless  due  to  hepatitis — the  so- 
called  tropical  abscesses.  A  variety  of  causes  are  concerned  in  the 
production  of  others.  The  habits  of  individuals  are  not  without  influ- 
ence, especially  the  use  of  stimulants,  highly  seasoned  dishes,  condi- 
ments, etc.     Suppuration  has  been  caused  by  the  impaction  of  calculi, 

*  "  Diseases  of  the  Liver."     Translated  by  Murchison.     Syd.  Soc,  vol.  ii,  p.  108. 

f  "  Clinical  Lectures  on  Diseases  of  the  Liver,"  etc.     Second  edition,  p.  IVY. 

X  "  An  Enquiry  into  the  Statistics  and  Pathology  of  some  Points  connected  with  Ab- 
scess of  the  Liver,  as  met  with  in  the  East  Indies."  By  Edward  John  Waring.  Trevan- 
drum,  1854. 

§  "  On  the  Diseases  of  the  Liver,"  p.  83,  et  seq. 

\  "  Transactions  of  the  Pathological  Society  of  London,"  vol.  xxiv,  p.  116,  18Y3. 


ABSCESS   OF   THE   LIVER.  153 

by  the  lodgment  of  a  liimbricoid  worm,  etc.  It  is  a  more  common 
malady  in  men  than  in  women,  and  from  the  twentieth  to  the  thirty- 
fifth  year.  A  case  is  reported  by  Grainger-Stewart,  in  which  abscess 
of  the  liver  followed  dilatation  of  the  bile-ducts.* 

Pathological  Anatomy. — That  a  certain  projDortion  of  cases  of 
hepatic  abscess  are  due  to  embolic  deposits,  coincident  ulcerations 
existing  in  the  intestine,  is  probably  true,  but  the  facts  of  observation 
which  support  this  theory  are  surprisingly  few.  Frerichs  f  reports  one 
of  embolic  blocking  of  a  vessel  at  the  site  of  a  commencing  abscess, 
and  a  few  others  have  been  recorded.  Forster  J  holds  that  a  miasmatic 
infection  of  the  blood  is  caused  by  the  ulceration  in  the  intestine. 
Whether  it  be  due  to  such  infection,  or  to  the  formation  of  a  thrombus 
and  subsequent  embolic  blocking  of  a  veinule  of  the  liver,  or  to  hepa- 
titis, or  to  any  other  cause,  the  initial  lesion  is  a  hyperoemia  of  the 
hepatic  cells  at  the  site  of  the  abscess.  The  cells  become  cloudy  and 
granular  by  the  presence  of  an  albuminous  matter  deposited  in  them. 
Liebermeister  maintains,  but  he  is  alone  in  this  opinion,  that  the  initial 
change  is  in  the  connective  tissue  ;  but  Rokitansky,  Virchow,  Frerichs, 
Forster,  and  others,  refer  the  first  changes  to  the  cells  of  the  hepatic 
parenchyma,  and  the  alterations  in  the  connective  tissue  to  a  subse- 
quent period. 

Those  parts  of  the  hepatic  parenchyma  in  which  the  liver-cells  are 
undergoing  disintegration,  at  first  have  a  reddish-yellow  appearance, 
and  at  some  points  contain  patches  of  pigment  of  a  bright  yellow 
color,  and  are  surrounded  by  a  translucent  pale-gray  ring.  The  acini, 
the  seat  of  this  process,  are  distinctly  enlarged,  become  softer,  and 
disintegrate.  The  center  of  each  inflamed  patch  early  becomes  yel- 
low, which  indicates  the  beginning  of  suppuration.  The  size  of  these 
points  of  suppuration  is  at  first  small,  but  those  in  close  proximity 
coalesce,  forming  an  abscess — a  purulent  collection.  These  abscesses 
are  filled  with  pale-yellow  pus,  and  the  borders  of  the  collection  con- 
sist of  dark-red,  disintegrating  gland-tissue,  projecting  in  the  form  of 
softening  shreds  into  the  purulent  depot.  They  vary  in  size  from  a 
pea  to  a  hen's  egg,  or  may  attain  much  larger  dimensions.  Important 
changes  take  place  in  these  purulent  collections  as  they  grow  older  : 
the  walls  become  smooth,  and  are  lined  by  connective  tissue,  the  pus 
thus  becoming  encysted,  or  absorption  occurs,  the  walls  of  the  abscess 
approximate,  unite,  and  ultimately  nothing  remains  but  a  linear  cica- 
trix. So  perfectly  does  repair  go  on  and  is  completed,  that  in  some 
years  afterward  scarcely  a  trace  of  the  original  mischief  can  be  de- 
tected.    In  other  cases  no  limiting  membrane  is  produced,  the  inflam- 

*  T.  Grainger-Stewart,  "  The  Edinburgh  Medical  Journal,"  January,  18Y3. 
f  "  Diseases  of  the  Liver,"  op.  cit. 

X  "  Lehrbuch  der  pathologischen  Anatomie  von  Dr.  August  Forster."  By  Dr.  Siebert. 
Jena,  1873,  p.  26*7. 


154  DISEASES   OF  THE   LIVER. 

mation  extends,  and  an  enormous  purulent  collection,  which  tends  to 
external  discharge  in  some  direction,  is  formed,  and  enlarges  by  con- 
tinual accessions  of  purulent  matter.  It  does  not  often  happen  that 
such  a  collection  bursts  into  the  peritoneal  cavity,  exciting  fatal  peri- 
tonitis, but  it  tends  to  perforate  the  abdominal  wall,  or  dissects  down- 
ward along  the  spine,  discharging  in  the  inguinal  region  or  by  the  sa- 
crum posteriorly,  or  it  ulcerates  through  into  the  stomach,  duodenum, 
or  colon,  or  makes  its  way  upward,  perforates  the  diaphragm,  the 
lungs,  and  is  discharged  through  the  bronchi.  These  abscesses  have 
also  entered  the  vena  cava  (case  of  Colin  *),  have  ulcerated  into  the 
pericardium,  etc.,  but  such  accidents  are  comparatively  rare. 

The  size  of  an  abscess  of  the  liver  varies  from  an  ounce  or  two  to  a 
gallon.  In  69  cases  in  which  this  point  was  noted,  16  contained  one 
to  two  pints,  and  12  two  to  three  pints  ;  and  these  may  be  regarded 
as  of  the  usual  sizes.  As  respects  limitation  by  a  neo-membrane,  the 
cases  are  not  numerous  in  which  definite  statements  are  made  ;  in  53 
the  abscesses  were  encysted  in  36  and  not  limited  in  17,  but  it  is 
doubtful  if  this  relation  exists  throughout  a  large  number  of  unse- 
lected  cases.  Of  Waring's  300  cases,  169,  or  somewhat  more  than  one 
half,  remained  intact ;  of  the  remainder,  much  the  largest  number  of 
the  spontaneous  discharges  occurred  by  the  thoracic  cavity — 42 — and 
of  these  28  occurred  through  the  right  lung.  As  respects  the  lobe  of 
the  liver,  which  is  usually  the  seat  of  the  abscess,  the  statistics  of  vari- 
ous observers  agree.  Selecting  Waring's  300  cases  for  exemplification, 
we  find  that  the  purulent  collection  was  in  the  right  lobe,  alone,  in 
163,  and  in  both  right  and  left  in  35,  The  number  of  abscesses  present 
at  the  same  time  is  influenced  greatly  by  the  cause  ;  in  the  pysemic, 
there  may  be  a  dozen  or  more  ;  in  the  other  form,  from  one  to  three 
usually.  Although  fetid  decomposition  is  not  uncommon,f  yet  true 
gangrene  is  very  rare. 

Symptoms. — Notwithstanding  the  importance  of  the  organ,  abscess 
of  the  liver  of  considerable  size  may  exist  without  there  being  any 
local  or  systemic  symptoms  to  indicate  its  presence.  These  latent 
cases  occur  in  the  course  of  chronic  dysentery  and  pyremia,  and  fail  of 
recognition  because  masked  by  existing  symptoms,  or  they  are  latent 
because  the  inflammation  occurred  in  the  deepest  part  of  the  right  lobe^ 
and  did  not  involve  the  peritoneum,  nor  did  the  abscess  compress  the 
bile-ducts,  and  was  limited  by  a  neo-membrane.  A  typical  case  fol- 
lowing a  recognized  injury,  or  due  to  impaction  of  calculi,  will  present 
characteristic  symptoms,  and  the  diagnosis  will  be  easy,  but  many 
other  cases  may  not  only  be  diflicult  of  recognition,  but  in  some  a 
diagnosis  will  not  be  possible. 

The  onset  is  marked  by  the  phenomena  which  attend  an  inflamma- 

*  "Gazette  Hebdomadaire  de  Med.  et  dc  Chir.,"  No.  33,  1872. 
f  Rigal,  "L'Uuion  Med.,"  No.  134,  18Y3. 


I 


•ABSCESS   OF   THE   LIVER.  I55 

tory  affection  ;  a  chill,  or  chilliness,  aching  of  the  back  and  limbs,  head- 
ache, a  drj'  skin,  a  coated  tongue,  bilious  vomiting,  increased  action  of 
the  heart,  a  rise  in  the  arterial  tension,  are  the  systemic  symptoms. 
Locally,  there  is  a  feeling  of  uneasiness,  constriction,  weight,  dragging, 
and  often  considerable  pain  and  tenderness,  especially  if  the  hepatic 
peritoneum  is  involved.  In  some  cases  a  pain  is  felt  in  the  to])  of 
the  shoulder — a  tensive  pain — and  it  is  experienced  in  the  right  shoul- 
der when  the  right  lobe  is  affected,  and  in  the  left  shoulder  if  the 
left  lobe  is  the  seat  of  mischief,  and  in  some  cases  in  both  simultane- 
ously. Its  value  as  a  symptom  is  not  great,  for  it  is  present  in  other 
hepatic  diseases,  and  may  be  a  merely  rheumatic  or  neuralgic  pain. 
On  palpation  and  mensuration,  an  increase  in  the  size  and  density 
of  the  liver  can  usually,  but  not  invariably,  be  made  out.  The  area  of 
hepatic  dullness  is  increased  in  all  directions,  and  may  be  considerably 
so  if  the  purulent  collection  is  a  large  one.  Pushing  up  the  diaphragm 
and  displacing  the  lung,  the  area  of  dullness  and  the  absence  of  voice 
and  breath  sounds  may  extend  up  to  the  fourth,  to  even  the  lower 
margin  of  the  third  rib,  and  downward  several  finger-breadths  below 
the  margin  of  the  false  ribs,  furnishing  all  the  signs  of  hydropneurao- 
thorax.*  Jaundice  is  present  in  less  than  one  third  of  the  cases,  and 
then  varies  much  in  intensity,  but  it  is  general,  and  the  urine  is  loaded 
with  bile-pigment,  and,  when  the  liver  is  much  damaged,  contains  leucin 
and  tyrosin  instead  of  urea.  Jaundice  appears  early  in  those  cases  of  ab- 
scess due  to  the  impaction  of  calculi — soon  after  or  with  the  initial  symp- 
toms, which  are  those  of  hepatic  colic — and  much  later  in  those  which 
are  the  usual  cases,  due  to  the  pressure,  on  the  hepatic  duct,  of  the  ab- 
scess. When  pus  forms  there  is  usually  a  decided  rigor,  and  these  shiv- 
erings  recur  irregularly,  and  are  followed  by  fever  and  sweats.  Like 
the  other  characteristic  symptoms,  these  are  often  entirely  absent.  The 
fever,  chills,  and  sweats  are  much  more  pronounced  in  the  so-called 
pyjemic  abscesses  than  in  those  arising  from  hepatitis.  The  irritability 
of  the  stomach  is  enhanced  by  the  occurrence  of  suppuration  ;  the  fre- 
quency and  persistence  of  the  vomiting  at  this  period  is  an  important 
indication,  much  insisted  on  by  Maclean  f  and  Fayrer.;^  The  vomiting 
may  have  the  bilious  character,  with  a  large  evacuation  of  bile,  and  the 
alvine  dejections  may  have  the  same  character  ;  the  vomit  may  consist 
of  watery  mucus,  and,  rarely,  of  blood.  There  will  be  an  increase  of 
the  dysenteric  symptoms,  if  this  disease  had  been  in  existence  when 
the  abscess  formed,  or  diarrhoea  or  dysentery  may  occur  when  suppura- 
tion takes  place.  The  size  of  the  liver  lessens  somewhat,  and  the  area 
of  hepatic  dullness  diminishes  when  pus  forms,  if  the  abscess  be  in- 

*  Rigal,  "L'Uuion  5Ied.,"  Xo.  134,  1873. 

f  "  The  Diagnostic  Value  of  Uncontrollable  Vomiting."    Dr.  W.  C.  Maclean,  "  British 
Medical  Journal,"  August  1,  18*73. 

X  Sir  Joseph  Fayrer,  ibid.,  September  26,  1873. 


156  DISEASES   OF  THE   LIVER. 

closed  ;  but,  if  no  limiting  membrane  is  formed,  the  dimensions  of 
the  organ  gradually  enlarge.  The  diminution  in  size  is  maintained, 
and  a  gradual  return  to  the  normal  is  the  rule,  when  the  pus  is  ab- 
sorbed and  the  cavity  cicatrizes.  Fluctuation  is  felt  and  can  be  de- 
tected only  when  the  purulent  collection  attains  to  great  dimensions. 
If  the  abscess  tends  to  spontaneous  recovery  by  absorption,  or  after 
discharge  of  pus,  the  local  pain  and  tenderness  subside,  the  pulse  falls 
to  the  normal,  the  stomach  is  no  longer  irritable,  appetite  returns,  and 
digestion  is  resumed.  If,  however,  the  abscess  enlarges,  the  distress  in 
the  hepatic  region  and  the  tenderness  increase  ;  movements,  esj)ecially 
of  breathing  and  coughing,  awaken  deep-seated  soreness  and  pain  ; 
breathing  becomes  difficult  by  pressure  on  the  lungs  ;  the  heart  is  some- 
times displaced  upward  and  to  the  left,  which  adds  to  the  existing 
pr^ecordial  uneasiness  and  to  the  difficulty  of  breathing  ;  and  a  harass- 
ing and  painful  short,  dry  cough,  induced  by  irritation  of  the  pneu- 
mogastric  and  phrenic  nerve-filaments,  adds  greatly  to  the  distress. 
As  a  tendency  to  discharge  through  the  right  lung  exists  in  a  large 
proportion  of  cases,  the  base  of  this  lung  and  the  neighboring  pleura 
are  affected  by  a  localized  i^leuro-pneumonic  process,  with  the  usual 
physical  and  rational  signs  of  that  complication.  Adhesion  of  the 
pleural  surfaces  takes  place,  and  a  channel  is  formed  communicating 
with  a  bronchus,  through  which  discharge  occurs.  Less  often  a  sec- 
ondary suppurating  cavity  is  constructed  by  the  pleural  adhesions. 
Rarely  the  pericardium  is  opened,  and  death  caused  by  sudden  disten- 
tion of  the  sac  with  pus.  If  riipture  takes  place  into  the  peritoneal 
cavity,  this  untoward  accident  is  announced  by  sudden,  intense  pain 
and  collapse  ;  if  into  the  intestine,  purulent  and  bloody  evacuations 
indicate  it,  while  lessened  size  of  the  liver  and  less  tension  and  pain 
also  coincide;  if  the  pus  dissects  outwardly  through  thehypochon- 
drium,  a  large,  puffy,  and  fluctuating  tumor  forms. 

The  variations  in  the  symptoms  of  hepatic  abscess  are  very  re- 
markable. There  may  be  no  local  symjDtoms — no  pain,  no  tenderness, 
no  enlargementr  "When  the  purulent  collection  tends  downward  below 
the  ribs,  there  may  be  fluctuation,  and  when  it  has  attained  to  great 
dimensions  ;  but  it  is  a  comparatively  rare  symptom.  In  much  the 
largest  number  of  cases,  the  pus  forms  in  the  ujDper  and  superior  part 
of  the  right  lobe,  in  a  situation  where  fluctuation  can  not  be  developed. 
Pain  may  be  entirely  absent  :  in  ^Taring's  300  cases  of  hepatic  abscess, 
pain  was  not  present  in  20.  The  reflex  shoulder-pain  is  much  less  con- 
stantly experienced  ;  it  is  more  frequently  wanting  than  it  is  felt. 
Gastric  derangement  of  any  kind  may  not  exist,  and  the  patient  may 
have  a  good  appetite.  The  importance  of  severe  vomiting  as  a  symp- 
tom of  suppuration  is  not  impaired  by  the  fact  that  exceptional  cases 
are  encountered,  but  vomiting  and  severe  and  uncontrollable  vomiting 
are  highly  significant,  andvery  rarelyabsent.     Vomiting  is  increased  by 


ABSCESS   OF   THE   LIVER.  15Y 

extension  of  disease  to  the  peritoneum,  and  by  pressure  of  an  enlarging 
abscess  directly  upon  the  stomach.  Although  the  bowels  may  be  un- 
disturbed in  exceptional  cases,  dysentery  is  present  in  a  considerable 
proportion — according  to  Waring,  in  82  in  300  cases — but  dysentery 
sometimes  succeeds  to  the  abscess,  and  is  apparently  caused  by  it.  As- 
cites occasionally  occurs  when  the  abscess  compresses  the  portal,  and 
jaundice  usually  accompanies  it,  for  the  common  or  hepatic  duct  is  en- 
croached on  at  the  same  time. 

Course,  Duration,  and  Termination.— So  much  obscurity  exists  in 
regard  to  the  initial  symptoms,  so  much  variation  in  the  behavior  of 
cases,  that  no  defined  course  can  be  laid  down.  The  duration  is  equally 
uncertain  and  irregular.  A  typical  case  without  complication  may  pass 
thi-ough  its  several  stages  in  about  seventy  days  if  the  pus  is  discharged 
by  a  favorable  channel;  if  the  pus  undergoes  absorption,  and  the  cavity 
closes  by  cicatrization,  several  weeks  longer  will  be  necessary.  The 
initial  symptoms  will  occupy  less  than  a  week,  for  suppuration  appears 
in  a  short  time  after  the  hyperoemia,  and  the  breaking  down  of  the  he- 
patic tissue  proceeds  rapidly,  so  that  an  abscess  of  considerable  size  will 
form  in  seven  to  ten  days.  Then  comes  on  a  period  of  septicaemic  fever 
— remittent  in  type,  with  irregular  sweats,  in  the  acute  cases  with  ab- 
scess of  large  size,  and  intermittent  with  long  periods  of  freedom  from 
fever  in  the  subacute  and  chronic  cases,  with  abscess  of  moderate  size. 
The  course  of  abscess  of  the  liver  is  much  affected  by  the  development 
of  a  limiting  neo-membrane.  When  this  membrane  is  formed,  if  no 
complications  are  present,  there  may  be  a  "latent  period"  of  consider- 
able duration — a  period  characterized  by  the  absence  of  local  and  sys- 
temic symptoms.  This  quiescent  state  may  continue  several  weeks, 
months  even  ;  then  acute  symptoms  arise,  which  are  often  misinter- 
preted, and  supposed  to  be  the  initial  symptoms,  and  the  abscess  formed, 
the  product  of  the  recent  disturbance.  If,  on  the  other  hand,  there  is 
no  limiting  membrane  formed,  and  the  suppuration  extends,  the  septi- 
caemic fever  persists,  and  the  patient  sinks  into  a  typhoid  state,  with 
low-muttering  delirium,  and  death  from  exhaustion. 

Cases  of  acute  abscess  without  complication,  discharging  in  a  favor- 
able direction,  recover  with  considerable  promptitude.  Early  and  suc- 
cessful use  of  the  aspirator  for  the  evacuation  of  pus  shortens  the  du- 
ration of  a  case  materially.  Convalescence  is  very  tedious  when  fistulous 
communication  exists  through  the  lungs,  the  parietes  of  the  abdomen, 
and  elsewhere.  The  author  has  met  a  case  of  fistula  of  the  right  hy- 
pochondrium  discharging  somewhat  after  eighteen  months.  During 
the  existence  of  such  purulent  formation  and  discharge,  night-sweats, 
diarrhoea  or  dysentery,  a  poor  appetite,  and  feeble  digestion  combine 
to  maintain  a  condition  of  debility  for  a  long  time,  or  there  may  be  a 
continuous,  gradual  failure,  terminating  in  exhaustion  and  death.  In 
the  acute  cases  which  terminate  fatally  there  are  usually  intense  hectic, 


158  DISEASES   OF   THE   LIVER. 

profuse  sweats,  uncontrollable  vomiting,  and  rapid  failure  of  the  vital 
powers.  The  cases  associated  with  dysentery  are  very  protracted  and 
very  fatal  ;  they  rarely  cicatrize,  and  less  frequently  discharge  exter- 
nally than  do  the  uncomplicated  cases  (Frerichs).  The  condition  of 
patients  who  recover  is  not  always  that  of  health.  Very  often  the  in- 
testinal digestion  is  impaired  because  of  the  insufficient  supply  of  bile, 
and  the  functions  of  the  stomach  and  intestines  are  interfered  with  by 
adhesions  and  contracting  bands  of  lymph  which  limit  the  movements 
of  these  organs  and  narrow  their  capacity,  or  obstruct  the  passage  of 
their  contents. 

Prognosis. — How  favorable  soever  may  be  the  apparent  condition 
in  any  case  of  hejiatic  abscess,  the  prognosis  must  be  guarded,  for  un- 
expected complications  may  arise,  and  the  known  dangers  are  uncer- 
tain in  their  behavior.  The  pyasmic  abscesses  are  more  numerous,  are 
due  to  a  poisoned  state  of  the  blood,  and  are  always  fatal.  The  direc- 
tion taken  by  the  abscess  is  an  important  element  in  coming  to  a  con- 
clusion ;  discharge  by  the  lungs  is  most  favorable  ;  by  the  external  in- 
tegument the  next,  and  by  the  intestinal  canal,  third.  Early  evacua- 
tion by  the  aspirator  lessens  materially  the  dangers  and  must  enter 
into  the  question  of  prognosis.  In  eighty-one  cases  of  hepatic  abscess 
evacuated  by  operation,  collected  by  Waring,  there  were  fifteen  recov- 
eries— 18'5  per  cent.  In  McConnell's,*  fourteen  cases  in  which  the 
aspirator  was  used,  six  died  and  eight  recovered — fifty-seven  per  cent. 
Both  sets  of  statistics  were  gathered  in  India,  but  the  former  were 
cases  which  occurred  before  1850,  and  the  latter  since  the  aspu'ator 
came  into  use.  Of  twenty-five  caSes  of  recovery  without  interference, 
also  by  Waring,  there  were  ten  in  which  the  matter  was  discharged 
through  the  lungs,  and  seven  by  stool.  The  size  of  the  abscess,  its 
position,  the  condition  of  the  patient  in  resj^ect  to  digestion  and  nutri- 
tion, and  especially  the  presence  or  absence  of  complications,  are  ele- 
ments which  must  be  taken  into  consideration  in  coming  to  conclu- 
sions. 

Diagnosis. — Hepatic  abscess  may  be  confounded  with  echinococcus 
of  the  liver,  dropsy  of  the  gall-bladder,  scirrhus,  abscess  of  the  ab- 
dominal wall,  efi^usions,  especially  purulent,  into  the  right  thoracic 
cavity,  etc. 

A  tumor  or  enlargement  formed  by  echinococci  is  unaccompanied 
by  pain  or  tenderness,  the  growth  is  slow  and  without  constitutional 
disturbance,  when  palpated  is  elastic,  fluctuating,  and  furnishes  that 
most  characteristic  sensation,  "the  purring  tremor."  An  abscess  of 
such  a  size  would  be  accompanied  by  pain,  tenderness  on  pressure,  by 
septicaemic  fever,  at  least  frequently  ;  there  would  be  wasting  and 
diarrhoea,  often  severe  vomiting,  and  the  sense  of  fluctuation  would 

*  Eemarks  on  pneumatic  aspiration  with  cases  of  abscess  of  the  liver  treated  by  this 
method.     "Indian  Annals  of  Medical  Science,"  July,  1S72. 


ABSCESS  OF  THE  LIVER.  159 

be  free  from  purring  tremor.  The  very  important  aid  to  diagnosis 
afforded  by  the  exploring  trocar  should  not  be  neglected,  and  its  indi- 
cations may  indeed  be  decisive.  The  fluid  of  an  abscess  is  purulent, 
and,  if  hepatic,  contains  portions  of  the  tissue  of  the  liver  ;  *  if  of  a 
hydatid  cyst,  a  straw-colored,  serous  fluid,  containing  the  character- 
istic echinococcus  booklets.  An  enlarged  gall-bladder  is  a  pyriform 
tumor  of  variable  size,  elastic  and  fluctuating  when  its  contents  are 
fluid,  or  hard  and  nodular  when  enlarged  by  calculi.  When  the  ac- 
cumulation is  a  product  of  the  metamorphosis  of  bile  and  mucus,  the 
growth  is  very  slow,  and  the  symptoms  nil — a  very  different  history 
from  that  of  abscess  ;  on  the  other  hand,  a  purulent  fluid  forming,  will 
be  accompanied  by  hectic,  sweats,  emaciation,  etc.,  and  a  differentia- 
tion is  not  possible.  In  cases  of  this  kind  there  has  been  a  history  of 
attacks  of  hepatic  colic  ;  the  last  one  having  determined  the  series  by 
a  closure  of  the  cystic  duct.  Abscesses  of  the  abdominal  wall  of  large 
size,  and  situated  in  the  right  hypochondriura,  may  be  very  confusing, 
but  the  distinction  may  be  made  by  the  history,  which  does  not  in- 
clude any  disturbance  in  the  hepatic  functions,  and  has  not  been  pre- 
ceded by  any  symptoms  of  disease  of  any  kind.  The  history  begins 
with  the  formation  of  a  tumor  in  the  hypochondrium.  The  most  cer- 
tain means  of  diagnosticating  consists  in  the  microscopic  examination 
of  the  purulent  matter,  and  in  determining  by  the  passage  of  the  aspi- 
rator needle  that  the  pus  is  contained  in  an  abscess  exterior  to  the  ribs. 
It  is  impossible  to  decide  between  an  hepatic  abscess  and  an  abscess 
formed  between  the  hepatic  and  parietal  peritoneum,  which  may  be 
the  result  of  a  local  peritonitis,  or  of  an  hydatid  cyst  undergoing  de- 
struction by  suppuration.  Multiple  abscess  of  the  liver  has  been  mis- 
taken for  cancer  of  the  stomach.f  The  pain,  vomiting,  wasting,  may 
mislead,  but  the  marked  difference  in  the  history  of  the  two  affec- 
tions, as  well  as  the  local  symptoms,  ought  to  prevent  such  an  error. 
The  most  difficult  problem  in  the  diagnosis  of  hepatic  abscess  is  the 
distinction  between  abscess  and  empyema,  or  hydrothorax.  Besides 
the  evidence  of  the  accumulation  of  fluid  filling  in  the  space  from  the 
diaphragm  to  the  fourth,  even  to  the  third  rib,  there  are  almost  always 
present  the  symptoms  of  a  pneumonia  in  preparation  for  the  evacua- 
tion by  the  lung.  The  physical  signs  will  be  the  same,  but  the  his- 
tory of  the  case  will  exhibit  important  differences  :  in  the  one  case  the 
accumulation  of  fluid  will  have  been  preceded  by  the  signs  and  symp- 
toms of  pleurisy  or  pleuro-pneumonia  ;  in  the  other,  by  the  signs  and 

*  Dr.  Samuel  Fenwick,  "Lancet,"  November  lY,  187*7,  "On  the  Detection  of  Particles 
of  Hepatic  Structure  in  Abscess  of  the  Liver."  The  pus  is  shaken  up  with  some  distilled 
water  and  put  aside  in  a  conical  wineglass.  When  settled,  it  is  examined  with  the  mi- 
croscope, or  it  is  shaken  up  with  some  distilled  water  to  which  a  few  drops  of  ammonia 
have  been  added,  and  then,  after  subsidence,  examined. 

f  Dr.  W.  Crumb,  "Philadelphia  Medical  and  Surgical  Reporter,"  March  14,  1873. 


160  DISEASES   OF   THE  LR^ER. 

symptoms  of  hepatic  inflammation.  Here,  again,  the  aspirator  may 
be  invoked  to  make  the  diagnosis  clear — the  presence  or  absence  of 
bits  of  hepatic  tissue  will  prove  the  abscess  to  involve,  or  not,  the  liver- 
substance. 

Treatment. — As  suppuration  occurs  so  promptly  after  the  initial 
hypersemia,  it  is  doubtful  whether  any  effort  to  prevent  the  formation 
of  pus  can  be  successful,  but  the  extension  of  the  area  may  be  checked 
or  limited.  As  soon  as  the  symptoms  manifest  themselves,  a  large 
dose  of  quinia  (twenty  grains)  should  be  given  at  once,  and  decided 
cinchonism  be  maintained  by  the  same  dose  at  proper  intervals,  or  by 
smaller  doses  more  frequently.  That  quinia  has  the  power  to  check 
the  migration  of  the  white  corpuscles  is  well  established,  but  it  is 
equally  true  that  large  doses  are  necessary  to  accomplish  this.  Mor- 
phia should  be  combined  with  it,  unless  some  contraindication  exist, 
and  especially  if  there  be  much  pain  and  the  peritoneum  be  involved. 
Warm  fomentations  and  turpentine-stupes  should  be  applied  over  the 
right  hypochondrium.  At  the  earliest  moment  when  the  existence  of 
pus  can  be  made  out,  or  there  are  good  reasons  to  suspect  its  presence, 
an  exploratory  puncture  with  the  aspirator  should  be  made.  The  re- 
cent experiences  of  Cameron,*  Condon, f  and  Sachs  J  have  demon- 
strated that  when  the  pus  can  be  reached  and  evacuated  a  very  large 
proportion  of  eases  recover  immediately.  It  is  a  remarkable  fact  that 
many  cases  in  which  the  symptoms  of  abscess  exist,  and  yet  no  pus  is 
found,  are  greatly  benefited  by  the  puncture.  The  modern  experiences 
have  demonstrated  also  that,  penetrated  by  suitable  needles,  no  injury 
is  done  to  the  liver,  and  that  repair  takes  place  so  perfectly  that  after 
death  no  trace  of  the  operation  is  visible.  The  necessity  for  early 
evacuation  of  the  pus  consists  in  this,  that  only  a  portion  of  these  ab- 
scesses are  confined  by  a  limiting  membrane,  and  that  those  thus  re- 
stricted do  not  long  remain  encapsulated,  but  tend  to  make  their  way 
externally.  In  Condon's  collection  of  cases  there  were  eight  of  abscess 
evacuated  by  the  trocar,  of  which  four  recovered,  and  three  of  heija- 
titis,  without  suppuration,  in  which  the  trocar  was  inserted  deeply  in 
the  right  lobe,  all  of  which  were  much  relieved  by  the  puncture  and 
promptly  cured.  In  Sachs's  collection  of  twenty-one  cases  there  were 
eight  recoveries  after  puncture — being  in  the  proportion  of  thirty-eight 
per  cent.  Under  the  old  system  of  using  the  knife  or  trocar,  when  the 
pus  was  already  pointing,  as  represented  in  the  statistics  of  Waring, 
there  were  sixty-six  deaths  in  eighty-one  cases,  making  the  percentage 
of  recoveries  18'o.     When  the  abscess  is  large,  and  repeate'd  punctures 

*  "The  London  Lancet,"  1863,  June  6th  and  loth— "On  the  Treatment  of  Acute 
Hepatitis  in  its  Suppurative  Stage." 

f  Ibid.,  August,  1877,  Dr.  E.  H.  Condon — "On  the  Use  of  the  Aspirator  in  Hepatic 
Abscess." 

^  "  Ueber  die  Hepatitis  der  heissen  Lander,"  etc.,  von  Dr.  Sachs  in  Cairo,  op.  cit. 


ACUTE  YELLOW  ATROPHY.  161 

are  necessary,  the  author  has  had  excellent  results  from  the  injection 
of  tincture  of  iodine  ;  it  lessens  the  formation  of  matter  and  prevents 
its  decomposition.  Mercury  was  formerly  much  used  in  all  hepatic 
affections,  but  that  it  is  injurious  in  abscess  is  now  disputed  by  no  one. 
It  is  probable  that  the  sulphides,  so  much  and  successfully  employed  in 
external  suppuration,  will  be  found  adapted  to  the  treatment  of  hepatic 
abscess.  The  sulphides  of  sodium  and  calcium  and  the  sulphurous 
mineral  waters  are  suitable  agents  to  be  so  exhibited.  As  the  vital 
resources  of  the  patient  are  severely  strained,  the  strength  should  be 
carefully  husbanded  from  the  beginning.  The  diet  must  be  generous, 
and  stimulants  judiciously  administered.  When  suppuration  has  oc- 
curred, the  alcoholic  stimulants  must  be  given  freely.  For  the  dysen- 
tery present  in  so  many  cases,  ipecac  is  the  best  remedy,  if  prescribed 
in  the  necessary  quantity — 3j  every  three  or  four  hours.  If  thei'e 
are  present  old  ulcerations  of  the  intestinal  tract,  copper  sulphate  is  an 
efficient  remedy  ;  but  usually  the  astringents  in  turn  will  be  adminis- 
tered in  vain. 


GENERAL  PARENCHYMATOUS  HEPATITIS— ACUTE   YELLOW- 
ATROPHY. 

Definition. — As  the  hepatitis  terminating  in  suppuration  is  con- 
fined to  a  part  of  the  liver,  it  has  been  designated  Local  Parenchyma- 
tous He]Datitis,  while  the  term  General  Parenchymatous  Hepatitis  is 
applied  to  Acute  Yellow  Atrophy,  which  consists  in  an  acute  diffused 
inflammation  involving  the  whole  organ,  and  terminating  in  atrophy. 
Various  names  have  been  applied  to  this  disease,  as  "  malignant  jaun- 
dice," "  typhoid  icterus,"  "  hsemorrhagic  icterus,"  etc. 

Causes. — Various  theories  have  been  proposed  to  account  for  the 
origin  of  acute  yellow  atrophy.  It  has  been  referred  to  an  excess  in 
the  production  of  bile,  to  stasis  of  the  bile,  to  sudden  saturation  of  the 
hepatic  cells  with  biliary  matters  contained  in  the  blood  of  the  portal 
vein.  Budd  supposes  it  to  be  caused  by  some  special  blood-poison  of 
unknown  nature,  which  acts  especially  on  the  liver.  These  hypotheses 
are  without  facts  to  support  them.  That  it  is  an  acute,  diffuse,  paren- 
chymatous inflammation  is  established  by  the  most  recent  investiga- 
tions, but  the  exciting  cause  of  this  inflammation  remains  unknown. 
That  it  is  in  the  nature  of  a  specific  morbid  poison  seems  probable, 
since  other  organs  are  simultaneously  attacked.  There  are  certain 
points  in  the  etiology  of  the  disease,  however,  which  are  well  known  ; 
it  occurs  most  frequently  in  the  female  sex,  and  during  the  state  of 
pregnancy.  According  to  the  statistics  of  Frerichs,  in  thirty-one  cases 
of  this  disease  twenty-two  were  females,  and  one  half  of  these  were 
attacked  during  the  state  of  pregnancy.  It  occurs  from  the  third  to. 
the  sixth  month  of  pregnancy,  and  in  comparatively  young  subjects, 
11 


162  DISEASES  OF  THE  LIVER. 

under  forty,  and  rarely  indeed  after  thirty  years  of  age.  Other  causes 
have  been  supposed  to  exert  an  influence  in  its  production  :  as  anger — 
a  violent  passion  having  been  the  apparent  cause  in  cases  reported  by 
the  older  writers — venereal  excesses,  syphilitic  infection,  and  local 
miasms.  Acute  atrophy  of  the  liver  has  been  induced  by  the  changes 
resulting  from  typhus  fever.  A  condition  analogous  to  it  is  brought 
aboiit  by  the  action  of  phosphorus,  arsenic,  antimony,  and  certain 
other  minerals,  and  a  similar  state  has  been  induced  by  subacute  alco- 
holismus  (Rendu). 

Pathological  Anatomy. — The  liver  presents  a  most  characteristic 
appearance — it  is  much  smaller,  flattens  out  by  its  own  weight,  is  soft 
so  that  it  tears  easily,  and  has  a  uniform  yellow  color.  The  peritoneal 
layer  is  roughened  and  wrinkled.  On  microscopical  examination,  the 
changes  seen  are  those  due  to  interstitial  and  parenchymatous  exuda- 
tion. There  is,  at  first,  an  hypersemia,  traces  of  which  are  discoverable 
at  various  points,  the  rest  of  the  organ  being  ansemic,  a  result  of  the 
subsequent  atrophy  and  obliteration  of  vessels.  Between  the  lobules 
there  is  deposited  a  grayish-yellow  material,  which  widens  the  inter- 
lobular space,  and  in  those  cells  which  are  still  recognizable  is  con- 
tained a  quantity  of  an  albuminous  and  fatty  matter  mixed  with  pig- 
ment.* In  the  place  of  the  disintegrated  cells  there  is  formed  a  quan- 
tity of  brownish,  fatty  granular  matter  ;  fat-globules  ;  pigment ;  bac- 
terian  colonies, f  and  needles  of  tyrosin  and  leucin.  The  ultimate 
radicles  of  the  portal  system  and  the  hepatic  artery  are  obstructed  or 
obliterated.  The  kidneys  also  undergo  characteristic  changes,  espe- 
cially in  the  cases  occurring  in  pregnancy.  The  organs  are  thoroughly 
stained  by  the  icteric  urine,  especially  the  endothelium  of  the  tubules, 
and  besides  the  cells  of  the  endothelium  have  become  infiltrated  by  a 
granular  albuminous  matter,  and  are  iindergoing  fatty  degeneration. 
The  urine  is  heavily  loaded  with  bile-pigment,  and  usually  contains 
some  albumen ;  the  urea  is  diminished  or  has  disappeared,  and  is  re- 
placed by  leucin  and  tyrosin.  In  the  normal  condition  of  the  liver  it 
is  now  regarded  as  probable  that  the  urea  which  is  eliminated  by  the 
kidneys  is  produced  in  the  former  organs  by  the  metamorphosis  of  the 
albuminoids.  The  blood  contains  considerable  urea,  and  much  leucin 
in  acute  atrophy  of  the  liver.  The  spleen  is  usually,  but  not  invari- 
ably, increased  in  size.  The  muscular  tissue  of  the  heart  undergoes 
more  or  less  fatty  change,  but  this  alteration  is  common  to  many  acute 
diseases.  Spots  of  ecchymosis  form  in  the  peritoneum,  the  gastro-in- 
testinal  mucous  membrane,  in  the  skin,  etc.,  and  indicate  the  destruc- 
tive changes  which  have  occurred  in  the  blood. 

Symptoms. — This  formidable  malady  begins  insidiously — as  a  sim- 

*  Drs.  Lewitski  und  Brodowski — Virchow's  "  Archiv,"  Band  Ixx,  p.  421 — "Ein  Fall 
Ton  sogennanter  acuter  gelber  Leberatrophie." 
f  Ibid.,  Band  xliii,  p.  533.     Waldeyer. 


ACUTE  YELLOW   ATROPHY.  163 

pie  catarrh  of  the  stomach  and  duodenum,  with  a  slightly  coated 
tongue,  nausea  and  vomiting,  headache,  tenderness  of  the  epigastrium, 
and  a  slight  icterode  hue  of  the  skin  which  gradually  deepens.  There 
are  some  acceleration  of  the  circulation  and  slight  fever,  which,  how- 
ever, are  not  constant,  for  the  pulse  may  and  usually  does  have  the 
feebleness  and  slowness  belonging  to  jaundice.  The  duration  of  these 
mild  symptoms  is  by  no  means  constant — they  may  occupy  a  week  or 
more  ;  and,  from  the  appearance  of  decided  jaundice  to  the  onset  of 
the  serious  symptoms,  there  may  be  a  few  houi's  to  two  weeks.  Some- 
times the  severe  symptoms  come  on  with  the  jaundice  and  a  day  or 
two  before  the  temperature  rises.  An  obstinate  insomnia  now  begins, 
and  the  headache  becomes  intense.  This  period  has,  by  some,*  been 
entitled  the  icteric  period.  According  to  Frerichs,  these  symptoms  of 
gastro-duodenal  catarrh  exist  in  about  one  half  of  the  cases,  and  the 
duration  of  them  may  be  from  three  to  five  days,  although  in  some 
cases  they  last  two  to  three  weeks.  In  one  casef  an  attack  of  jaun- 
dice preceded,  by  several  months,  the  fully  developed  attack. 

A  rise  of  temperature  either  precedes  or  accompanies  the  serious 
symptoms — the  toxcemic  period.  The  pulse  becomes  very  rapid,  rising 
to  140,  but  suddenly  again,  without  any  apparent  reason,  it  may  be, 
or  in  consequence  of  haemorrhage,  falling  to  70  or  80.  These  fluctua- 
tions, which  may  occur  several  times  a  day,  are  peculiar  to  the  dis- 
ease. When  the  cerebral  symptoms  come  on,  the  pulse  becomes  uni- 
form at  140  to  160.  The  temperature  line  is  of  the  remittent  type, 
with  a  morning  remission  (102°  Fahr.)  and  an  evening  exacerbation 
(104°  Fahr.).  Jaundice  is  constantly  present,  and  gradually  deepens 
from  its  first  appearance  ;  and  intermixed  with  it  are  large  brownish 
ecchymotic  patches,  but  these  are  not  always  present.  The  tongue 
and  gums  are  brownish,  dry,  and  covered  with  sordes  and  crusts,  and 
the  breadth  is  fetid.  There  are  much  nausea  and  vomiting,  and 
severe  pain  is  experienced  in  the  epigastrium  and  through  the  right 
hypochondrium,  and  pressure  over  the  hepatic  region  awakens  severe 
pain.  A  diminution  in  the  size  of  the  liver  can  be  readily  made  out 
by  percussion,  and  at  the  same  time  and  relatively  an  increase  in  the 
dimensions  of  the  spleen.  There  is  constipation  in  the  beginning, 
followed  by  more  free,  tarry  stools,  the  product  of  intestinal  haemor- 
rhage. Dui-ing  the  first  vomiting,  mucus  and  bilious  matters  are  dis- 
charged ;  but,  when  the  toxemic  symptoms  come  on,  blackish,  gru- 
mous  blood,  or  "  coffee-grounds,"  are  ejected.  There  are  more  or  less 
epistaxis,  bleeding  of  the  gums,  as  well  as  vomiting  of  blood,  and 
ecchyraoses  form  at  various  places.  The  urine  is  usually  normal  in 
quantity,  acid  in  reaction,  and  has  the  normal  specific  gravity.    When 

*  Jaccoud,  vol.  ii,  p.  418. 

f  Dr.  Joseph  Coates,  "The  British  Medical  Journal,"  June  26,  18Y5. 


1Q4.  DISEASES   OF  THE   LIVER. 

delirium  and  coma  exist,  the  urine  is  either  retained  or  passed  invol- 
untarily. Very  great  changes  are  noted  in  its  composition  :  the  urea 
is  diminished  in  amount,  the  phosphate  of  lime  disappears,  and  a  quan- 
tity of  leucin  and  tyrosin  and  extractives  are  substituted.  It  contains 
also  bile-pigment  and  traces  of  albumen,  and  cast-off  epithelium  deej)ly 
stained  with  bile-pigment.  There  must  necessarily  accumulate  in  the 
blood  those  excrementitious  matters  which  it  is  the  office  of  the  liver 
to  separate  from  the  blood,  and  this  fluid  is  deprived  of  those  con- 
tributions to  it  made  by  the  action  of  the  bile  in  the  digestion  of  cer- 
tain aliments.  We  can  not  therefore  subscribe  to  the  doctrine  of 
Flint,  who  assigns  to  cholesterin  the  toxic  effects,  which  are  doubtless 
produced  by  several  excrementitious  matters.  Instead  of  the  "cho- 
lestergemia  "  of  Flint,  we  hold  to  the  older  term,  cholasmia  or  acholia. 
These  poisonous  materials  act  on  the  nervous  system  in  a  manner 
similar  to  a  narcotic  poison,  producing  at  first  a  stage  of  excitation, 
followed  by  depression.  A  hypochondriacal  state,  with  irritability  and 
restlessness,  is  the  first  manifestation  of  mental  disturbance,  but  this 
is  soon  followed  by  noisy  delirium.  From  this  state  to  low-mutter- 
ing delirium  and  coma  the  transition  is  quick  ;  or  convulsions,  local 
twitching,  cramps,  and  general  epileptiform  attacks  occur,  soon  pass- 
ing into  coma  and  insensibility.  Sometimes  death  takes  place  in  te- 
tanic spasms.* 

Course,  Duration,  and  Termination. — The  behavior  of  acute  atrophy 
of  the  liver  is  irregular  :  the  prodromic  period,  the  stage  of  jaundice, 
and  the  toxsemic  stage,  are  uncertain  in  duration,  but  the  last  stage 
follows  a  more  uniform  plan.  After  the  development  of  the  jaundice 
period,  from  the  rise  of  temperature  and  the  insomnia  which  mark  the 
onset  of  the  toxsemic  stage  till  death,  the  most  usual  period  is  five 
days.  The  prodromic  stage  may  last  a  week  or  two,  the  jaundice 
stage  from  a  day  or  two  to  two  weeks,  the  toxsemic  stage  a  week,  but 
the  rule  is  that  the  whole  course  of  the  malady  is  included  within  a 
week.  The  termination  is  in  death.  Some  successful  cases  have  been 
reported,  but  it  is  doubtful  if  they  were  genuine.  It  may  be  that 
many  cases  treated  carefully  at  the  outset  have  been  an-ested  and 
cured,  but  such  cases  are,  as  far  as  we  are  informed,  simply  cases  of 
jaundice  from  catarrh  of  the  bile-ducts.  When  the  hepatic  cells  are 
disintegrated,  a  cure  can  hardly  be  possible. 

Diagnosis. — Acute  atrophy  is  probably  more  frequently  overlooked 
than  recognized.  It  is  impossible  to  differentiate  the  gastro-duodenal 
catarrh  of  this  disease  from  the  ordinary  examples  of  the  same  dis- 
ease. Great  importance  must  be  attached  to  the  increased  headache, 
rise  of  temperature,  and  obstinate  wakefulness  which  mark  the  onset 
of  the  toxsemic  stage.     As  so  many  of  these  cases  occur  in  pregnant 

*  Morand,  "Gazette  dcs  H6pitaux,"  20,  21,  1SY3. 


AMYLOID  LIVER.  165 

■women,  they  are  apt  to  be  confounded  with  puerperal  fever,  puerperal 
septicaimia,  etc. ;  but  the  physical  signs  of  a  rapidly  diminishing  liver, 
the  nervous  phenomena,  the  haemorrhages,  and  especially  the  changes 
in  the  urine,  will  serve  to  distinguish  between  them. 

Treatment. — Frerichs  reports  a  supposed  case  of  acute  atrophy, 
which  got  well  under  purgatives  and  mineral  acids.  This  appears 
to  be  the  routine  treatment.  If  the  disease  had  any  relation  to  the 
amount  or  quality  of  the  bile,  the  use  of  podophyllin,  euonymin,  ipe- 
cac, and  other  remedies  of  the  same  group,  is  indicated,  and  mineral 
acids  should  be  given  freely,  well  diluted,  in  small  doses  frequently 
repeated.  As  the  disease  is  a  diffuse  parenchymatous  inflammation,  the 
best  results  will  be  obtained  from  the  use  of  a  large  dose  of  quinia  and 
morphia  in  the  incipiency,  but  will  be  useless  when  the  liver-cells  have 
begun  to  disintegrate.  The  author  advises  the  trial  of  very  small 
doses  of  phosphorus,  as  early  as  possible,  as  this  remedy  affects  the 
organ  specifically,  and  an  action  of  antagonism  may  be  discovered 
between  them.  This  remedy,  as  all  others,  will  fail  to  do  the  least 
good,  if  disintegration  of  the  cells  has  occurred.  Alcoholic  stimulants 
should  be  pushed  freely,  notwithstanding  a  condition  not  unlike  acute 
atrophy  has  been  lately  observed  from  subacute  alcoholismus.* 

AMYLOID  LIVER. 

Definition. — By  this  term  is  meant  a  degeneration  of  the  liver  caused 
by  the  deposit  of  an  albuminoid  material,  termed  amyloid,  because  of 
a  superficial  resemblance  to  starch-granules.  This  disease  is  also  called 
"  waxy  liver,"  and  "  lardaceous  liver,"  in  recognition  of  the  peculiar 
physical  condition  of  the  organ. 

Causes. — The  chief  cause  of  amyloid  degeneration  of  any  organ  is 
prolonged  suppuration,  especially  in  connection  with  diseased  bone, 
and  the  morbid  process  is  then  general,  the  liver  suffering  in  common 
with  other  organs.  A  variety  of  explanations  have  been  offered  to  ac- 
count for  the  production  and  deposit  of  this  amyloid  matter.  The 
theory  of  Dr.  Dickinson,  which  assumes  that  this  matter  is  a  form  of 
fibrin,  altered  by  the  loss  of  its  alkali,  which  in  the  normal  state  is 
intimately  associated  with  it,  is  the  most  plausible.  According  to  this 
theory,  long-continued  suppuration  gradually  removes  in  the  pus  the 
alkali  from  the  fibrin,  which  is  then  deposited  in  various  organs  in 
the  form  of  the  amyloid  matter.  How  this  dissociation  of  alkali  and 
fibrin  is  effected  is  not  explained.  Although  the  explanatory  theories 
are  inadequate,  the  fact  of  the  relation  between  suppuration  and 
amyloid  deposit  is  not  disputed.     The  suppuration  of  tubercular  cavi- 

*  M.  H.  Rendu,  "  Note  sur  deux  cas  d'alcocilisme  subaigu  ayant  donne  lieu  h.  des  acci- 
dents comparables  ^  ceux  de  I'ictere  grave."  "La  France  Medicale,"  September  17, 
1879. 


1QQ  DISEASES   OF   THE   LIVER. 

ties,  of  scrofulous  abscesses,  of  intestinal  and  leg  ulcers,  etc.,  may  also, 
althougli  less  frequently,  be  a  cause  of  this  degeneration.  Next  to 
suppuration,  the  most  influential  factor  is  chronic  syphilitic  infection, 
and  then  chronic  malarial  poisoning.  The  abuse  of  mercury  is  an 
alleged  cause  which  Frerichs  disposes  of  satisfactorily.  This  morbid 
state  occurs  more  frequently  in  men  than  in  women,  and  attacks  by 
preference  the  most  active  period  of  life — from  twenty  to  forty  years 
of  age. 

^  Pathological  Anatomy. — The  liver  presents  a  very  characteristic 
appearance  :  it  is  uniformly  enlarged  without  alteration  of  the  form 
and  relation  of  its  parts,  and  sometimes  its  dimensions  are  enormous. 
It  presents  to  the  naked  eye  a  pale  grayish,  glistening,  opaline,  trans- 
lucent appearance,  and  to  the  touch  a  doughy  consistence.  On  section 
the  surface  is  homogeneous,  and  resists  the  knife  almost  like  cartilage, 
and  is  anaemic  and  whitish  ;  and  when  the  disease  is  far  advanced  no 
trace  remains  of  the  proper  structure  of  the  organ.*  There  may  be 
parts  only,  or  the  whole  organ,  affected  by  the  change.  The  deposits 
may  be  in  patches,  small  or  large,  and  restricted  to  parts  of  the  organ, 
or  be  uniformly  distributed  through  it,  and  may  be  so  limited  in  amount 
as  not  to  increase  its  size  (Frerichs).f  Cirrhotic  or  fatty  degeneration 
may  coexist  with  the  lardaceous,  when,  of  course,  the  appearances  will 
correspond.  The  reaction  with  iodine  and  sulphuric  acid  affords  a 
striking  test  of  the  amyloid  deposits.  The  parts  to  be  examined  must 
be  carefully  cleansed,  and  a  solution  of  iodine  with  iodide  of  jDOtassium 
in  water,  or  diluted  tincture  of  iodine,  brushed  over,  when  they  assume 
a  mahogany  color,  quite  different  from  the  yellow  color  of  the  healthy 
tissue.  This  reaction  may  be  sufficiently  characteristic  of  itself,  but,  if 
to  the  iodized  surface  is  now  added  some  diluted  sulphuric  acid,  the 
affected  parts,  after  some  minutes  or  hours,  take  on  a  violet  tint,  more 
rarely  bluish.  The  violet  may  be  very  deep,  almost  black.  Orth  | 
advises  that  a  large  and  thin  section  be  laid  in  a  saucer  of  water  con- 
taining some  iodine,  and,  when  the  changes  are  complete,  placed  on  a 
white  plate.  The  reaction  will  be  very  distinct.  Microscopically,  the 
structural  alterations  affect  first  the  arterioles  and  capillaries  ;  their 
diameter  is  increased,  the  lumen  narrowed,  even  closed ;  the  intima, 
the  endothelium,  and  the  muscular  coat,  more  rarely  the  adventitia,  are 
invaded  by  the  deposits.  The  cells  become  cloudy,  granular,  then 
clear,  bright,  and  homogeneous,  and  the  nuclei  disappear.  When  the 
process  is  completed,  the  cell  is  transparent,  glistening,  and  brittle, 
easily  breaking  up  into  small  fragments.§     The  amyloid  change  is  not 

*  Wagner,  "  Manual  of  General  Pathology,"  p.  322.     New  York  :  William  Wood  & 
Company.     18'76. 
\  Op.  cit. 

X  Orth,  "Diagnosis  in  Pathological  Anatomy,"  p.  321.     Riverside  Press.     1878. 
§  Forster,  op.  cit.,  p.  272. 


AMYLOID  LIVER.  167 

confined  to  the  liver,  but  involves  the  spleen,  the  kidneys,  the  lymphatic 
glands,  the  intestinal  mucous  membrane,  and  other  organs.  Those  por- 
tions of  the  liver  remaining  unaffected  by  this  morbid  deposit  are  in  a 
state  of  congestion,  and  are  softer ;  or  parts  of  the  organ  are  attacked 
with  fatty  or  ciri'hotic  degeneration,  or  syphilitic  gummata  may  be 
mixed  up  with  the  amyloid  deposits. 

Symptoms. — There  are  probably  no  exceptions  to  the  statement  that 
amyloid  degeneration  occurs  in  subjects  already  in  a  cachetic  state  by 
the  existence  of  one  or  more  of  the  causes  already  mentioned.  The 
symptomatology  is  necessarily  that  of  the  malady  with  which  this 
degeneration  is  associated,  up  to  the  time  of  the  development  of  those 
signs  by  which  the  disease  of  the  liver  is  recognized.  The  liver  is 
usually  enlarged,  and  often  considerably  so,  extending  several  finger- 
breadths  below  the  margin  of  the  false  ribs.  The  organ  is  smooth, 
firm  to  the  touch,  almost  of  stony  hardness,  it  may  be  ;  its  borders 
well  defined,  free  from  pain  or  tenderness,  unless  there  is  present  local 
peritonitis.  This  increase  of  size  has  gone  on  without  any  local  uneasi- 
ness to  call  attention  to  the  organ.  The  spleen  is  also  enlarged,  and 
is  firm  in  texture,  as  a  rule,  but  the  waxy  degeneration  does  not  always 
affect  it  when  enlarged  in  the  course  of  amyloid  liver.  Jaundice  is 
exceptional,  unless  the  common  duct  or  the  hepatic  duct  is  obstructed 
by  enlarged  lymphatics.  As  the  amyloid  change  first  affects  the 
branches  of  the  hepatic  artery,  the  portal  is  not  interfered  with  until 
later.  Ascites  exists  in  about  one  fourth  of  the  cases,  and  is  often  pre- 
ceded by  oedema  of  the  lower  extremities,  the  result  of  a  general  hydrje- 
mia.  The  appetite  is  usually  poor,  but  in  exceptional  cases  is  voracious. 
Food  in  the  solid  form  excites  uneasiness  soon  after  it  is  swallowed, 
and  is  rejected  by  vomiting,  or  passes  unchanged  in  the  faeces,  unless 
it  is  very  bland  and  capable  of  entire  solution  in  the  stomach.  The 
fatty,  starchy,  and  saccharine  articles  of  the  diet  undergo  decomi^osi- 
tion  in  the  intestine,  and  a  great  deal  of  gas — the  foul  compounds  of 
hydrogen  with  sulphur  and  phosphorus — is  the  result.  The  amount 
of  bile  passing  to  the  intestine  lessens  with  the  increase  of  the  deposit 
in  the  hepatic  cells,  and  ultimately  the  secretion  is  arrested,  and  the 
office  of  the  bile  in  preventing  putrefaction  and  in  emulsionizing  the 
fats  terminates.  The  obstruction  to  the  portal  circulation  maintains  a 
constant  hypersemia  of  the  gastro-intestinal  mucous  membrane.  As  a 
result  of  these  causes,  the  stomach  and  intestines  become  irritable,  and 
frequent  liquid  stools,  now  pale  from  the  absence  of  bile,  now  dark 
from  the  presence  of  blood,  are  passed.  Amyloid  degeneration  also 
invades  the  arterioles  of  the  mucous  membrane  and  the  substance  of 
the  villi,  and  destructive  ulcers  are  formed  in  consequence  (Frerichs). 
The  urine  is  pale,  abundant,  of  low  specific  gravity,  and  contains 
waxy  casts  and  a  trace  of  albumen.  It  is  not  surprising,  in  view  of 
the  structural  alterations  and  impairment  of  functions,  that  the  sub- 


168  DISEASES  OF  THE  LIVER. 

jects  of  amyloid  degeneration  present  a  peculiar,  anaemic,  and  pallid 
appearance,  are  breathless  on  the  least  exertion,  and  emaciate  rapidly. 

Course,  Duration,  and  Termination. — As  amyloid  degeneration  is 
preceded  by  suppuration,  or  some  chronic  wasting  disease,  the  moment 
this  change  begins  escapes  recognition.  Indeed,  the  peculiar  deposits 
have  been  quite  extensively  distributed  before  any  characteristic  symp- 
toms appear.  When  the  process  once  begins  it  extends  at  a  pretty 
uniform  rate,  and  death  takes  jjlace  by  exhaustion  and  general  dropsy, 
or  the  end  is  reached  by  an  intercurrent  malady,  as  pneumonia,  pleurisy, 
etc.  Its  course  is  essentially  chronic  ;  its  duration  months  or  a  year 
or  more  ;  its  termination  fatal.  Notwithstanding  the  unfavorable 
prognosis,  the  disease  is  not  always  fatal,  and  cures  have  been  report- 
ed, especially  of  those  cases  having  a  syphilitic  history. 

Diagnosis. — The  enlargement  of  the  liver  due  to  amyloid  deposit 
is  to  be  differentiated  from  fatty  liver,  hydatid  disease,  cancer,  etc. 
From  fatty  liver  it  is  distinguished  by  the  greater  firmness  of  texture, 
the  well-defined  margin,  and  especially  by  the  accompanying  disorders 
of  the  spleen,  kidneys,  and  intestinal  canal.  From  hydatid  disease  it 
is  separated  by  the  same  signs,  and  by  the  characteristics  of  the  hyda- 
tid tumor,  which  enlarges  painlessly,  is  elastic,  and  furfiishes  on  pal- 
pation the  "purring  tremoi'."  The  changes  in  the  liver  pi'oduced  by 
cancer  are  secondary  to  the  original  deposit,  which  is  most  frequently 
in  the  stomach,  and  the  enlargement  of  the  organ  is  hard,  nodular 
and  irregular.  The  urinary  secretion  is  not  affected  in  cancer,  but 
jaundice  is  often  present. 

Prognosis. — Few  if  any  cases  of  true  amyloid  disease  recover,  and 
indeed  recovery  can  hardly  be  possible  when  the  hepatic  cells  are  en- 
tirely filled  with  such  a  material.  Cases  presenting  the  signs  of  amy- 
loid degeneration,  but  not  far  advanced,  have  recovered.  Although 
the  prognosis  is  grave,  it  is  not  necessarily  fatal. 

Treatment. — Prophylaxis  necessarily  occupies  an  important  position 
in  the  therapeutical  management  of  this  disease.  As  so  many — much 
the  largest  number — owe  their  origin  to  suppuration  of  bone  and  to 
syphilitic  infection,  it  is  highly  necessary  to  stop  the  influence  of  these 
morbid  processes  at  an  early  period  in  all  cases.  If  there  be  any  rea- 
son to  suspect  constitutional  syphilis,  ajDpropriate  treatment  should  be 
at  once  instituted,  and  the  most  efficient  remedy  under  these  circum- 
stances is  a  compound  of  iodine  :  the  compound  solution  of  iodine — 
ten  drops  in  water,  three  or  four  times  a  day,  may  be  given  ;  or,  if 
there  be  much  anaemia,  the  sirup  of  the  iodide  of  iron,  and  especially 
the  siru]D  of  the  iodides  of  iron  and  manganese.  The  author  has  had 
the  best  results  from  the  persistent  use  of  the  iodide  of  ammonium  in 
small  doses  frequently  repeated — five  grains  every  four  hours,  and 
well  diluted  with  water.  Budd  urges  the  employment  of  the  muriate 
of  ammonia  (ammonium  chloride),  but  the  iodide,  the  author  believes, 


CARCINOMA   OF   THE   LIVER.  169 

is  mucli  more  efficient.  Mercurials  are  injurious.  The  diet  should 
consist  of  those  alimentary  princijiles  which  undergo  digestion  and  ab- 
sorption in  the  stomach — as  milk,  animal  broths,  eggs,  fish,  etc.  ;  and 
starches — as  bread,  potato  and  rice — sugar  in  any  form,  and  fats,  ought 
to  be  avoided,  because  they  require  the  action  of  the  intestinal  juices. 
The  food-supplies  should  be  small  in  quantity,  and  given  frequently, 
because  of  the  intolerance  of  the  gastro-intestinal  mucous  niembrane. 
Inunction  of  fat,  especially  of  cod-liver  oil,  is  a  highly  useful  addition 
to  means  for  promoting  the  nutrition. 


CARCINOMA  OF  THE   LIVER. 

Etiology. — Nothing  is  definitely  known  as  to  the  origin  of  cancer, 
in  any  situation,  but  there  are  certain  facts  connected  with  its  develop- 
ment which  it  is  important  to  recognize.  It  is  a  disease  of  advanced 
life,  and  is  more  apt  to  appear  from  forty  to  sixty  than  at  any  other 
vigintennary.  But  cancer  of  the  liver  appears  in  early  life  relatively 
more  frequently  than  cancer  of  the  stomach.  It  occurs  with  about 
equal  frequency  in  the  two  sexes.  Heredity,  although  the  fact  can 
not  be  expressed  in  figures,  is  doubtless  the  most  influential  factor  in 
its  genesis. 

Pathological  Anatomy. — The  ordinary  form  of  cancer  is  found  in 
the  liver,  the  variety  being  determined  by  the  relative  proportion  of 
the  fibrous  stroma,  the  cells,  and  the  juice  ;  it  is  most  frequently 
medullary  or  encephaloid.  When  infiltrated  with  pigment  it  becomes 
melanoid,  and,  when  vessels  predominate,  telangiectatic  cancer,  but 
these  are  accidental  differences.  The  cancer  formation  may  be  in 
nodules  or  isolated  masses,  or  diffused  through  the  hepatic  parenchyma. 
The  size  of  the  nodules  varies  from  the  dimensions  of  a  pea  to  those  of 
a  child's  head  (Forster),  and  they  are  in  numbers  inversely  as  their 
size.  There  may  be  one  or  two  of  large  size,  or  a  great  many  of  small 
size,  distributed  through  the  substance  of  the  organ.  Those  on  the 
surface  are  rounded,  with  a  central  umbilication,  produced  by  a  fatty 
metamorphosis  of  the  center  of  the  mass  and  contraction  of  the  pe- 
ripheral portion.  The  peritoneum  is  adherent  usually,  and  is  cloudy, 
thickened,  and  covered  with  a  membranous  exudation,  or  it  may  re- 
main normal.  The  consistence  of  the  masses  varies  with  the  form  of 
the  cancer — it  is  soft,  brain-like,  or  almost  creamy,  or  it  is  hard  and 
cartilaginous.  The  explanation  of  the  origin  of  the  growth  differs,  but 
it  may  be  stated  that  the  cancer  develops  from  the  interlobular  con- 
nective tissue.  The  branches  of  the  hepatic  artery  are  intimately  con- 
cerned in  the  morbid  process  ;  they  increase  in  size,  and  permeate  the 
new  formation,  while  the  branches  of  the  portal  vein  shrink.  With 
the  development  of  the  cancer-cells  (by  division  and  endogenous  for- 


170  DISEASES  OF  THE  LIVER. 

mation  of  the  connective-tissue  corpuscles — "Wagner  *)  the  proper  he- 
patic cells  disappear.  The  new  vessels  developed  from  the  branches 
of  the  hepatic  artery  have  very  delicate  walls,  and  are  liable  to  rup- 
ture, infiltrating  the  cancer-masses  with  haemorrhagic  extravasation. 
When  the  periphery  of  the  organ  is  reached  by  the  new  foi-mation, 
haemorrhage  may  take  place  into  the  peritoneum,  and  sudden  death 
ensue  from  this  cause.  The  branches  of  the  portal  vein  are  compressed, 
or  they  may  be  filled  with  cancer-cells.  The  lymph  vessels  and  glands 
may  also  become  filled  and  infiltrated.  The  bile-ducts  are  compressed 
and  disappear,  except  the  larger  ducts,  which  become  dilated  into 
pouches  with  retained  bile,  or  pass  unchanged  through  the  cancer- 
masses.  The  growth  of  cancer'  is  not  continuous  and  uniform,  but 
paroxysmal,  as  it  were — now  rapid,  now  slower  ;  and  when  the  forma- 
tions have  existed  for  some  time  they  undergo  a  fatty  metamorphosis. 
It  is  this  change  in  the  interior  of  the  nodules  which  leads  ultimately 
to  the  umbilications  already  mentioned.  The  hepatic  parenchyma  not 
invaded  by  the  cancerous  new  formation  remains  unchanged,  or  is 
more  or  less  hypersemic,  or  undergoes  atrophy.  The  size  of  the  whole 
organ  is  usually  increased,  and  sometimes  it  attains  extraordinary 
dimensions,  weighing  ten,  fifteen,  or  twenty  pounds  (Frerichs).  Can- 
cer of  the  liver  is  rarely  primary,  but  is  secondary  to  a  deposit 
elsewhere,  most  frequently  in  the  stomach.  Of  ninety-one  cases  col- 
lected by  Frerichs,  forty-six  were  secondary  to  cancer  in  organs  hav- 
ing a  vascular  communication  with  the  liver,  and  cancer  was  primary 
to  the  liver  in  scarcely  one  fourth  of  the  cases.  The  author  has  met 
with  one  case  of  jDrimary  cancer  of  the  gall-bladder,  the  morbid  pro- 
cess apparently  beginning  in  the  exudation  of  a  local  peritonitis  caused 
by  the  passage  of  hepatic  calculi. 

Symptoms. — Cases  of  cancer  of  the  liver  are  occasionally  encoun- 
tered in  which  no  characteristic  symptoms  existed  ;  the  patient  has 
ill-defined  uneasiness  in  the  right  hypochondrium,  disorders  of  diges- 
tion, and  low  spirits  ;  he  emaciates  progressively,  is  cachectic,  and 
ultimately  dies.  Again,  cancer  of  the  liver  has  a  clinical  history  which 
is  merely  the  conclusion  of  a  series  of  symptoms  referable  to  cancer  in 
another  organ,  notably  the  stomach.  The  defined  symptoms  of  hepatic 
cancer  are  apt  to  be  obscured  by  some  leading  condition  associated 
with  it,  as  ascites.  Those  attacked  with  cancer  are  advanced  in  life 
as  a  rule.  Before  any  symptoms  of  disturbance  in  the  hepatic  func- 
tions manifest  themselves,  there  are  present  disorders  of  digestion, 
flatulence,  and  constipation.  Then  feelings  of  uneasiness,  of  weight, 
of  tension,  and  of  pain  in  the  right  hypochondrium  are  experienced. 
On  palpation,  soreness  is  developed  by  pressure,  and  the  liver  is  felt 

*  "  General  Pathology."     Translated  by  Drs.  Yan  Duyn  and  Seguin.    New  York,  ISTS, 
p.  503. 


CARCINOMA  OF  THE   LIVER. 


m 


stretching  beyond  the  margin  of  the  ribs  ;  it  is  indurated,  irregular  in 
outline,  and  nodulated.  In  the  further  progress  of  the  case,  the  liver 
extends  downward  still  more,  and  nodules  can  be  easily  made  out ;  the 
area  of  hepatic  dullness  is  increased  in  all  directions,  but  chiefly  down- 
ward, and  there  may  be  a  good  deal  of  spontaneous  pain  and  exquisite 
tenderness  on  pressure  by  reason  of  a  local  peritonitis. 

Jaundice  is  not  present  in  the  ma- 
jority of  cases,  and  exists  only  when 
the  lymphatic  glands  in  the  fissure  or 
the  cancer  nodules  are  enlarged  suiR- 
ciently  to  compress  the  hepatic  or 
common  duct.  Ascites  is  present  in 
about  one  half  of  the  cases,  and  is  pro- 
duced more  frequently  by  peritonitis 
than  by  compression  of  the  portal,  but 
this  vessel  is  obstructed  occasionally 
by  cancer  thromboses.  The  ascites 
may  be  so  considerable  as  to  produce 
great  distress  by  embarrassment  to 
respiration  and  by  interference  with 
the  circulation.     The  ascites  may  be  ij:     4.  S;;;;:;.;:-^^  | 

in  part  due  to  the  watery  condition  of  ^ 

the  blood.      The  fluid   is  a  pale,  straw-    Fig.  ll.-Area  of  Dullness  in  Cancer  of  the 

colored  serum,  or  it  contains  flocculi  ^^^®''" 

of  lymph  and  is  turbid,  or  it  is  mixed  with  blood,  the  source  of  which 
has  been  heretofore  alluded  to.  Gastro-intestinal  catarrh  is  set  up  by 
the  congestion  of  the  portal  system  ;  haemorrhoids  form  ;  haemorrhages 
occur  from  the  intestinal  mucous  membrane,  and  an  obstinate  watery 
diarrhoea  succeeds  to  the  constipation  which  was  an  early  symptom. 
All  of  these  causes  combine  to  produce  a  cachectic  state.  The  com- 
plexion gradually  assumes  the  char9,cteristic  earthy  or  fawn  color, 
emaciation  is  extreme,  the  feebleness  is  excessive,  the  hands  and  feet 
are  cold,  the  skin  is  dry  and  harsh,  and  the  expression  is  dejected  and 
worn. 

Course,  Duration,  and  Termination. — The  course  of  cancer  of  the 
liver  and  its  duration  are  much  influenced  by  its  form — the  medullary 
proceeding  to  a  fatal  termination  more  rapidly  than  scirrhus.  As 
already  stated,  the  progress  is  not  uniform,  the  growth  at  times  being 
suspended  and  then  again  quickening  into  renewed  activity.  Cases 
terminating  in  eight  weeks  have  been  reported,  and  others  continue 
with  varying  fortunes  for  months  and  years.  There  is  but  one  mode 
of  termination,  that  in  death. 

Diagnosis. — It  may  not  be  possible  to  diagnosticate  cancer  in 
those  cases  without  any  local  symptoms,  or  in  the  incipiency  of 
any  case.     When,  however,  the  enlarged  and  nodulated  liver  can  be 


172  DISEASES  OF   THE  LIVER. 

felt,  the  difficulty  of  diagnosis  is  much  less,  especially  if  the  patient 
is  of  advanced  age,  and  the  cachexia,  the  ascites,  etc.,  are  also  pres- 
ent. Distinction  is  to  be  made  between  cancer,  abscess,  echinococ- 
cus,  and  amyloid  disease  ;  in  all  these  the  liver  is  enlarged  (as  a  rule) 
and  projects  downward,  but,  in  cancer,  the  organ  is  nodulated  and 
indurated  ;  in  abscess  it  is  smooth  and  softer,  and  may  be  fluctu- 
ating ;  in  echinococcus  it  is  smooth,  elastic,  and  having  the  j)urring 
tremor  ;  in  amyloid  it  is  smooth  and  uniform,  but  indurated.  They 
differ  in  their  clinical  history  and  in  their  cause,  in  their  duration  and 
in  their  termination,  so  that  a  diagnosis  can,  in  well-marked  cases, 
be  readily  made. 

Treatment. — The  treatment  must  necessarily  be  palliative  and  symp- 
tomatic, as  there  is  no  remedy  for  cancer  in  any  situation.  Anodynes 
will  be  required  to  relieve  pain.  Careful  regulation  of  the  diet,  ac- 
cording to  the  conditions  present,  and  the  timely  administration  of 
stimulants  will  be  demanded.  Ascites  will  require  the  treatment  in- 
dicated for  that  disease,  especially  the  tapping — for  the  interference 
with  repose  caused  by  a  distended  abdomen  is  one  of  the  most  distress- 
ing complications. 

EOfllNOOOOCUS   OP   THE    LIVER    (HYDATID   DISEASE   OF  THE 

LIVER). 

Definition. — By  the  terms  echinococcus  of  the  liver,  hydatid  dis- 
ease, cystic  degeneration,  multilocular  cyst,  etc.,  is  meant  the  penetra- 
tion into  the  liver  of  the  scolex  of  the  sexually  immature  taenia  echi- 
nococcus. The  embryos,  gaining  access  to  the  intestines  of  man,  mi- 
grate, and,  doubtless  chiefly  by  the  portal  vein  and  bile-ducts,  reach 
the  liver  in  which  the  cyst  or  cysts  develop,  sometimes  attaining  im- 
mense size. 

Causes. — As  the  echinococcus  is  the  taenia  of  the  dog,  only  those  who 
live  in  a  humble  way,  with  their  animals  about  them,  suffer  from  these 
migratory  parasites.  As  the  ova  are  discharged  with  the  excrement 
of  the  dog,  it  is  obvious  that  they  can  gain  admission  to  the  human 
stomach  only  through  the  most  filthy  practices,  or  by  carelessness  in 
the  obtaining  and  storing  of  drinking-water  and  food.  In  Iceland,  more 
than  in  any  other  part  of  the  world,  do  the  people  suffer  from  cystic 
disease — as  large  a  proportion  as  one  sixth  of  the  pojDulation  being 
infected.  This  preponderance  of  the  disease  is  due  to  the  number  of 
dogs  and  to  the  promiscuous  way  in  which  the  members  of  a  family 
and  their  dogs  live  together  in  their  wretched  hovels.  The  disease 
occurs  at  the  middle  period  of  life  chiefly,  and  rarely  in  the  young. 
In  the  only  case  of  echinococcus  of  the  liver  met  with  by  the  author, 
the  patient,  a  male,  was  forty-two  years  of  age. 

Pathological  Anatomy, — When  the  echinococcus  (or  two  or  more) 


HYDATID   DISEASE   OF   THE   LIVER.  173 

lodges  in  the  liver  it  is  presently  enveloped  in  a  tough,  fibrous,  yellow- 
ish-white membrane,  constructed  out  of  the  adjacent  connective  tissue, 
and  closely  adherent.  "Within  this  adventitious  membrane  is  contained 
the  embryo,  inclosed  in  a  clear,  translucent  sac  made  up  of  numerous 
concentric  layers.  This  sac  of  the  embryo  is  the  mother-sac,  and  in  the 
interior  of  it  a  number  of  so-called  daughter-vesicles,  and  still  other, 
granddaughter-vesicles,  are  developed,  and  ultimately  the  mother-sac, 
with  its  investing  membrane,  attains  to  extraordinary  dimensions.  The 
daughter-vesicles  vary  in  number  from  a  few  up  to  many  thousands, 
and  in  size  from  that  of  a  pea  to  that  of  a  goose-egg.  The  fluid  of  the 
sac  is  clear,  opalescent,  weakly  alkaline,  and  of  a  specific  gravity  of 
1"008  to  1"013  ;  it  contains  no  traces  of  albumen,  but  a  large  proportion 
of  sodium  chloride  and  some  crystals  of  cholesterine  and  hasmatoidine.* 
The  inner  membrane  of  the  daughter-vesicles  is  lined  with  a  germinat- 
ing layer,  from  which  the  embryos  spring  ;  and  scolices,  attached  as 
well  as  free,  can  be  observed  within  the  sacs.  These  scolices  are  the 
immature  tceniro,  and  can  be  recognized  with  a  low  power — sixty  diam- 
eters— as  possessed  of  a  head,  four  suckers,  and  a  row  of  booklets. 
When  detached,  these  scolices  have  the  power  of  active  motion,  and 
can  withdraw  their  probosces  and  booklets  within  their  own  cavity. 
There  are  hydatids  without  daughter-vesicles,  and  others  entirely  with- 
out a  scolex,  which  were  denominated  by  Laennec  acephalocysts,  and 
by  Kiichenmeister,f  sterile  echinococci.  There  are  great  variations 
in  the  size,  number,  and  position  of  the  cysts.  They  are  found  in 
all  the  lobes,  but  most  frequently  in  the  right,  bm-ied  in  the  sub- 
stance or  projecting  from  the  surface  of  the  organ.  Usually  but  one 
cyst  exists,  but  there  may  be  several — as  many  as  five  or  six.  It 
follows  that  the  size,  shape,  and  appearance  of  the  liver  will  vary 
with  the  number,  position,  and  growth  of  the  cysts.  It  may  attain 
a  sufficient  size  to  distend  the  abdominal  cavity,  or  at  least  make  a 
great  protrusion  in  the  right  side.  With  the  growth  of  the  cyst, 
the  hepatic  tissue  is  correspondingly  atrophied,  by  being  encroached 
upon,  while  the  rest  of  the  organ  remains  intact,  or  undergoes  hyper- 
trophy, or  is  hypersemic.  As  a  rule,  the  cysts  do  not  obstruct  the 
large  blood-vessels  and  bile-ducts  ;  hence  the  infrequency  of  ascites 
and  jaundice  ;  yet  both  may  be  encroached  upon — even  obliterated. 
It  sometimes  happens  that  communication  is  established  between  bile- 
ducts  and  the  cyst,  by  the  breaking  through  of  the  duct  in  the  course 
of  development  of  the  cyst,  and,  bile  entering,  the  growth  of  the  echi- 
nococcus  is  arrested.  The  cysts  sometimes  penetrate  the  common  duct, 
also  the  gall-bladder,  and  rarely  the  portal  vein.  They  may  be  dis- 
charged through  the  ducts  and  a  cure  be  thus  effected,  but,  if  they 

*  Davaine,  "Traite  dea  Entozoaires."     Paris,  1872,  p.  0*79. 
f  "  Animal  and  Vegetable  Parasites,"  op.  cit. 


174. 


DISEASES  OF  THE  LIVER. 


enter  the  veins,  thrombi  form,  with  the  usual  disastrous  results.  Echi- 
nococci-cysts  may  undergo  calcification.  The  adventitious  envelope 
hecomes  thicker  and  tougher,  and  calcareous  salts  are  deposited ;  ex- 
pansion and  growth  are  prevented  ;  the  parasites  die,  and  are  found 
flattened  and  contracted.  In  other  cases  there  is  developed  in  the 
interior  of  the  capsules  a  dense,  honey-like  or  puriform  fluid,  which 
had  previously  been  clear  and  then  milky,  and  remains  of  the  scolices, 
especially  the  booklets,  are  found  floating  in,  or  mixed  with,  the  con- 
tained fluid.  Crystals  of  hsematoidinae  and  bile  also  are  found  mixed 
with  the  contents  of  wasting  cysts. 


Fig.  12.    Isolated  Scolex  of  the  Tonnia  echinococcus, 
from  the  Pig 


Fig.  12.— Tcenia  eeldnococcus,  from  the  Pig. 


Fig.  14. — Tcenia  ecMno- 
coceus,  from  the  Dog. 


A  great  many  cysts  are  destroyed  and  cease  to  grow,  as  has  been 
described,  but  many  continue  to  enlarge,  pushing  up  the  diaphragm 
and  displacing  the  heart,  and  reaching  cometimes  as  high  as  the  second 
rib  (Frerichs).  Others,  growing  downward  from  the  under  surface  of 
the  liver,  push  aside  the  stomach,  and  force  the  abdominal  organs  into 
the  pelvis,  or,  but  rarely,  compress  the  ascending  vena  cava,  causing 
cedema,  varicose  veins,  etc.  A  cyst  may  rupture  into  the  cavity  of 
the  chest — into  the  pleural  or  pericardial  sac,  causing  fatal  inflamma- 
tion, or  excavate  a  cavity  in  the  right  lung,  and  shreds  and  parts  of  the 
vesicles  be  discharged  through  the  bronchi  by  expectoration.     A  cyst 


HYDATID   DISEASE   OF  THE   LIYER. 


175 


may  also  rupture  into  the  peritoneum,  producing  fatal  peritonitis,  or 
into  the  intestines,  and  be  slowly  discharged  by  stool.  Rupture  within 
the  abdomen  is  usually  due  to  a  blow  or  other  injury,  but  is  sometimes 
spontaneous.  The  echinococcus  multilocularis,  which  was  formerly 
mistaken  for  colloid  cancer,  but  has  since  been  accurately  described 
by  Virchow,  differs  from  the  ordinary  form,  in  that  it  is  a  very  firm, 
hard  tumor,  consisting  of  dense  fibrous  tissue,  containing  cavities  filled 
with  a  gelatinous  material.  On  account  of  its  tendency  to  ulcerative 
degeneration,  Yirchow  called  it  the  "  ulcerative  multilocular  echinococ- 
cus-tumor."  Friedreich  *  holds  that  the  development  of  this  form 
takes  place  in  the  gall-ducts  and  blood-vessels. 

Symptoms. — A  cystic  tumor  of  small  size,  deeply  placed,  and  not  so 
situated  as  to  interfere  with  other  parts,  may  not  cause  any  symptoms, 
and  therefore  remain  undetected.  But  a  cyst  of  considerable  size,  pro- 
jecting from  the  liver,  or  which  has  increased  the  size  of  the  organ, 
and  especially  if  it  has  encroached  upon  neighboring  parts,  will  cause 
sufficient  disturbance  of  function  to  lead  to  its  early  recognition.  If 
a  cystic  tumor  increases  to  any  considerable  extent  the  volume  of  the 
liver,  there  will  be  a  feeling  of  weight,  heaviness,  and  dragging  in 
the  right  hypochondrium,  and  some  disorders  of  digestion  ;  if  it  hap- 
pen to  be  near  the  hilus  of  the  organ,  the  portal  vein  and  the  com- 
mon or  the  hepatic  duct  may  be  pressed 
upon,  causing  ascites  and  jaundice  ;  if 
near  or  at  the  upper  convex  surface  of 
the  right  lobe,  the  diaphragm  will  be 
pushed  up,  and  a  dry  cough  and  dysp- 
noea will  be  the  result.  The  degree 
of  enlargement  is  necessarily  various. 
The  tumor  may  fill  in  the  whole  space 
from  the  inferior  border  of  the  second 
rrib  to  the  pelvis,  displacing  the  tho- 
acic  and  abdominal  organs,  and  forc- 
ing out  the  intercostal  spaces.  The 
tumor  may  take  various  forms  :  the 
liver  may  be  uniformly  enlarged  ; 
there  may  be  a  growth  projecting 
from  the  borders  of  the  organ,  and 
having  a  globular  or  hemispherical 
form  similar  to  that  of  the  gall-blad- 
der ;  or,  one  lobe  may  be  the  seat  of 
the  growth,  the  other  remaining  intact. 

On  palpation,  an  hydatid  tumor  is  elastic,  resisting  but  soft,  fluctu- 
ating, and,  in  somewhat  more  than  half  the  cases,  presenting  the  pecu- 


Fia.  15. — Liver  enlarged  by  Hydatid  Cysts. 


*  Virchow's  "  Archiv,"  vol.  xxxiii,  p.  16,  "  Ueber  multilokuIarenLeber-echinokokkus.'' 


1Y6  DISEASES  OF   THE  LIVER. 

liar  fluctuation  known  as  "  jsurring  tremor,"  or  "hydatid  purring"  — 
a  sensation  aj)preciated  by  the  sense  of  touch  as  the  trembling  of  a 
bowl  of  jelly  appears  to  the  eye.  The  tumors  are  not  painful,  and  it 
is  exceptional  for  any  tenderness  to  be  felt  on  pressure.  Jaundice  or 
ascites  occurs  only  in  the  rather  rai'e  event  of  a  tumor  near  the  hilus, 
or  so  situated  as  to  compress  the  vein  and  duct.  Dyspnoea  and  cough 
occur  when  the  cyst  develops  into  the  thorax  ;  irregular  action  of  the 
heart,  when  this  organ  is  pushed  from  its  position  ;  constipation  and 
vomiting,  when  the  intestines  and  stomach  are  encroached  upon  ;  swol- 
len and  (Edematous  feet  and  ankles  and  enlarged  veins,  when  the  cava  is 
compressed.  All  of  these  symptoms  arise,  when  the  form  and  direction 
of  the  cyst  develop  them,  without  any  constitutional  disturbance,  and 
if  such  disturbance  occur  it  is  due  merely  to  the  interference  of  the 
growth  with  important  functions.  If  the  echinococcus  burst,  new 
symptoms  arise.  If  the  stomach  is  entered,  there  will  be  some  local 
pain,  and  the  parasites  will  be  rejected  by  vomiting,  often  in  immense 
numbers  ;  if  the  intestine  is  perforated,  the  parasites  are  discharged 
by  stool,  and  recovery  may  ensue  in  either  case.  If  the  vena  cava  is 
entered,  sudden  death  with  the  symptoms  of  asphyxia  takes  place.  If 
the  pleural  cavity  receive  the  echinococci,  pleuritis  is  excited,  and  the 
cysts,  with  the  products  of  inflammation,  may  be  subsequently  dis- 
charged through  the  lung  by  a  bronchus.  If  the  pericardium  is  sud- 
denly filled  with  echinococci,  the  action  of  the  heart  is  disturbed,  and 
fatal  pericarditis  quickly  excited. 

Course,  Duration,  and  Termination. — The  hydatid  disease  is  essen- 
tially chronic  in  its  course.  The  development  of  the  cyst  is  affected 
by  its  surroundings  ;  and  in  the  interior  of  organs,  subjected  to  pres- 
sure on  all  sides,  the  growth  is  slower  than  if  it  is  deposited  on  the 
surface.  They  last  from  one  or  two  years  up  to  thirty,  but  the  most 
usual  duration  is  two  to  four  years.  They  may  undergo  a  spontaneous 
cure  :  the  echinococci  die,  or  on  the  opening  of  bile-ducts  they  are 
killed  by  the  entrance  of  bile,  and  subsequently  shrivel  up  ;  they  are 
discharged  through  the  stomach  and  intestine,  or  by  the  bronchi,  and 
recovery  slowly  ensues.  Death  is  not  unfrequently  produced  by  echi- 
nococci— by  gradual  failure  of  the  powers  of  life  ;  suddenly,  by  en- 
trance of  the  parasites  into  the  vena  cava  or  the  pericardium  ;  and 
gradual  failure  by  pneumonia,  or  suppuration,  or  pysemia. 

Diagnosis. — Echinococci  of  the  liver  may  be  confounded  with  ab- 
scess, cancer,  dropsy  of  the  gall-bladder,  aneurism,  and  hydrothorax. 
It  differs  from  abscess,  cancer,  and  hydrothorax  by  the  absence  of  pain 
and  constitutional  disturbance  ;  from  abscess,  by  the  character  of  the 
fluctuation  ;  and  from  cancer,  by  absence  of  the  hard,  non-fluctuating 
nodules  of  the  latter.  From  dropsy  of  the  gall-bladder  it  is  distin- 
guished by  the  lack  of  a  history  of  attacks  of  hepatic  colic,  their  ces- 
sation and  the  enlargement  of  the  gall-bladder  coming  on  slowly  ;  but 


HYDATID   DISEASE   OF   THE   LIVER.  177 

the  distinction  is  most  certainly  made  by  the  use  of  the  aspirator,  since 
it  has  been  shown  that  this  organ  may  easily  and  with  perfect  safety 
be  penetrated  by  the  needle.  From  aneurism,  echinococci  are  readily 
differentiated  by  the  existence  of  a  heaving,  expansile  pulsation  in  the 
former,  without  the  peculiar  fluctuation  of  the  latter.  There  is  more 
real  difficulty  in  separating  hydatids  pushing  up  the  diaphragm,  from 
effusions  into  the  pleural  cavity,  as  the  physical  signs  are  the  same. 
An  attentive  consideration  of  the  previous  history  will  aid  materially 
in  arriving  at  conclusions.  The  growth  of  echinococcus  is  slow  and 
painless,  and  the  development  of  the  local  symptoms  is  free  from  that ' 
disturbance  which  precedes  the  occurrence  of  an  effusion  in  the  chest. 
But,  above  all  other  means  for  coming  to  a  correct  conclusion,  must 
be  placed  the  use  of  the  aspirator  and  the  microscopic  examination  of 
the  fluid. 

Prognosis. — "VYhen  the  echinococcus  is  large,  and  its  particular 
direction  unknown,  the  prognosis  is  grave.  The  early  use  of  the  as- 
pirator enters  largely  into  the  question  of  prognosis,  for  early  punc- 
ture will  insure  the  death  of  the  parasite.  When  discharge  takes 
place  by  the  stomach  and  intestine,  the  prognosis  will  be  favorable  ; 
and  recovery  may  also  be  expected  in  those  cases  discharging  by  the 
bronchi,  provided  the  right  lung  is  only  so  far  damaged  as  to  permit 
the  passage  of  the  cysts.  When  there  is  a  large  suppurating  cavity 
in  the  right  lung  the  prognosis  is  unfavorable. 

Treatment. — There  is  no  medicinal  treatment  which  can  in  any  way 
affect  the  origin  or  growth  of  the  echinococci.  Fortunately,  we  possess 
simple  surgical  measures  by  which  these  cysts  may  be  safely  and  cer- 
tainly closed.  These  are,  puncture  by  an  aspirator  needle  and  with- 
drawal of  some  of  the  fluid,  and  electrolysis.  Whenever  a  cyst  can 
be  reached  by  the  needle,  it  can  be  subjected  to  either  of  these  expe- 
dients. The  simple  puncture  and  withdrawal  of  some  of  the  fluid  con- 
tained in  the  mother-vesicle  should  be  tried  first,  as  this  has  succeeded 
in  numerous  instances.  This  failing,  the  method  by  electrolysis  should 
be  practiced.  Dr.  Hilton  Fagge  and  Mr.  Durham  *  report  eight  cases 
in  which  electrolytic  decomposition  was  employed  with  entire  "success. 
Two  needles  connected  with  the  negative  pole  were  inserted  into  the 
sac,  and  the  positive  pole,  in  the  form  of  a  large  sponge-electrode,  was 
applied  on  the  integument  in  the  neighborhood.  Ten  cells  were  used 
to  furnish  the  current,  and  the  needles  were  permitted  to  remain  ten 
minutes.  As,  in  the  process  of  electrolytic  decomposition,  hydrogen  and 
the  alkalies  (potassa,  soda)  appear  at  the  negative  pole,  it  is  obvious  that 
the  parasites  must  be  killed  by  the  electrolytic  action.  Besides  these 
measures,  iodine  has  been  injected  into  the  mother-sac  with  success. 

*  "  Medico-Chirurgical  Transactions,"  vol.  clir,  "  On  the  Electrolytic  Treatment  of 
Hydatid  Tumors  of  the  Liver,  with  an  Addendum  on  Simple  Acupuncture." 
12 


178  DISEASES   OF   THE   LIVER. 

ANEURISM  OF  THE  HEPATIC  ARTERY.— The  author  can  add 
one  to  the  few  examples  of  aneurism  of  the  hepatic  artery.  The  size 
of  the  tumor  in  the  reported  cases  has  varied,  but  the  tumor  can  not 
always  be  felt,  or  rupture  takes  place  before  it  has  attained  sufficient 
dimensions  to  be  felt  through  the  abdominal  parietes.  In  one  instance 
the  liver  was  displaced  by  it.  Usually,  long  before  the  existence  of  a 
tumor  can  be  made  out,  severe  pains  are  exj^erienced  in  the  right 
hypochondrium.  The  attacks  of  pain  are  at  first  paroxysmal,  and  can 
hardly  be  distinguished  from  hepatic  colic,  but  in  the  further  progress 
of  the  case  there  are  constant  pain  and  soreness  in  the  right  hypochon- 
drium, and  paroxysms  of  severe  pain.  The  pressure  of  the  aneurism 
on  the  hepatic  plexus  is  the  cause  of  the  early  appearance,  severity, 
and  persistence  of  the  pain.  Jaundice  is  usually  present,  due  to  pres- 
sure on  the  hepatic  or  common  duct,  and,  in  the  case  referred  to  by 
the  author,  ascites  was  the  prominent  symptom.  The  interference 
with  the  hepatic  functions,  the  constant  suffering,  etc.,  cause  rapid 
failure  of  the  vital  powers  ;  the  flesh  wastes,  the  skin  appears  earthy 
or  jaundiced,  the  digestive  functions  are  disordered  in  consequence  of 
the  absence  of  bile,  and  ascites  may  slowly  accumulate.  Death  takes 
place  by  rupture  and  escape  of  the  blood  into  the  peritoneal  cavity. 
In  one  case  (Frerichs)  blood  was  regurgitated  by  the  stomach,  and  it 
reached  this  organ  by  a  circuitous  channel ;  communication  by  a  very 
small  orifice  was  established  between  the  sac  of  the  aneurism  and  the 
gall-bladder,  and  a  small  quantity  of  blood  continually  passed  from 
the  gall-bladder  to  the  duodenum,  and  thence  by  retching  into  the 
stomach. 

THROMBOSIS  OF  THE  PORTAL  VEIN  is  a  result  of  various  ob- 
structive conditions,  as  cirrhosis,  chronic  atrophy,  cancer,  and  tumors. 
The  symptoms  due  to  the  thrombosis  are  those  of  obstruction  to  the 
portal  circulation,  and  occur  rather  abruptly  in  the  course  of  the 
chronic  malady  associated  with  it.  The  pressure  in  the  initial  radi- 
cles of  the  portal  vein  is  suddenly  increased,  and  free  transudation  of 
blood  occurs  along  the  intestinal  mucous  membrane,  haemorrhoids 
form,  and  a  watery  diarrhoea  takes  place.  The  spleen  enlarges,  and 
ascites  develops  with  great  rapidity.  Efforts  toward  a  compensatory 
circulation  are  made  by  the  communicating  veins,  which  suddenly 
appear  enlarged  on  the  surface  of  the  abdomen.  The  urine  becomes 
scanty  and  of  high  specific  gravity.  The  patient  presents  a  very  de- 
cided cachexia,  the  strength  rapidly  fails,  and  death  occurs  in  a  few 
days  or  weeks.  The  obstruction  by  the  thrombus  is  not  always  com- 
plete, so  that  an  imperfect  circulation  is  maintained.  In  that  case 
the  symptoms  will  be  less  formidable  and  the  progress  less  rapid. 
The  only  remedy  which  offers  any  prospect  of  relief  is  ammonia, 
which  has  the  power  to  dissolve  coagula.     Unfortunately,  the  stasis 


PYLEPHLEBITIS.  179 

in  the  portal  system  so  hinders  absorption  that  remedies  do  not  readily 
enter  the  blood.  As  Halfourd,  of  Australia,  has  demonstrated  the 
innocuousness  of  the  intravenous  injection  of  ammonia,  this  expedient 
should  be  practiced  in  such  cases.  It  consists  in  the  injection  of  one 
part  of  aqua  ammonite  to  two  parts  of  water  into  any  convenient  vein. 
If,  however,  there  be  any  movement  of  blood  in  the  portal,  the  am- 
monia should  be  administered  in  the  form  of  the  carbonate  —  five 
grains  every  three  hours.  The  usual  remedies  for  ascites  will  be 
necessary. 

SUPPURATIVE  INFLAMMATION  OP  THE  PORTAL  VEIN,  or 
SUPPURATIVE  PYLEPHLEBITIS. — This  is  always  a  secondary  dis- 
ease, and  has  its  origin  in  suppuration  occurring  at  some  point  in  the 
distribution  of  the  portal  vein.  An  inflammation  occurs  in  the  tunics 
of  the  vessel,  which  become  soft  and  discolored  by  the  presence  of 
a  fluid  and  fibrinous,  purulent  exudation,  and  by  imbibition  of  the 
hsematine.  The  intima  especially  is  discolored,  brownish,  yellowish, 
or  greenish-yellow,  and  is  covered  with  layers  of  fibrin  and  pus.  The 
changes  extend  to  and  involve  the  adventitia.  A  thrombus  forms  in 
the  vessel  and  undergoes  characteristic  alterations,  softens  in  the  cen- 
ter, becomes  yellow,  the  fibrin  breaking  up  into  a  granular  mass,  and 
the  hsemoglobulin  disintegrating  and  gradually  forming,  with  the  rest 
of  the  thrombus,  a  purulent-looking  fluid.  Thrombi  form  most  fre- 
quently in  the  hepatic  branches  of  the  portal,  and  emboli  in  some  cases 
are  deposited  in  other  parts  of  the  liver,  and  secondary  pygemic  abscesses 
occur  in  various  parts  of  the  body. 

Suppurative  inflammation  of  the  portal  vein  is  associated  with  and 
is  dependent  upon  ulcerations  in  various  parts  of  the  intestinal  mucous 
membrane,  or  suppuration  and  abscesses  in  the  mesenteric  glands,  or 
the  inflammation  and  ulceration  following  impaction  by  gall-stones, 
etc.  The  symptoms,  therefore,  succeed  to  those  of  the  malady  which 
caused  it.  The  initial  symptom  is  pain,  and  it  is  felt  in  the  umbilical 
region,  in  the  iliac  region,  or  in  the  hypochondrium,  according  to  the 
branch  of  the  portal  implicated  ;  then  follows  a  severe  rigor,  which, 
after  a  period  of  high  temperature,  terminates  in  a  profuse  sweat. 
These  paroxysms,  intermittent  in  type,  are  repeated,  not  in  a  regular 
order,  but  at  uncertain  intervals.  In  the  interval  the  temperature  is 
rather  subnormal ;  during  the  j)yrexia  the  temperature  rises  to  105°  or 
106°  Fahr.,  and  the  sweats  are  most  exhausting.  The  liver  enlarges 
and  is  tender,  and  jaundice  appears.  The  spleen  also  enlarges,  doubt- 
less because  of  the  obstruction  in  the  portal  circulation.  Usually  there 
is  a  profuse  diarrhoea,  the  discharges  consisting  of  a  reddish,  watery, 
and  fetid  fluid,  sometimes  of  bilious  matter.  The  abdomen  becomes 
tender,  and  is  much  distended  ;  vomiting  comes  on  ;  the  exhausting 
alvine  discharges  continue,  and  hence  the  powers  of  life  rapidly  decline. 


180  DISEASES  OF  THE  LIVER. 

The  secondary  deposits  excite  local  distress,  and  each  addition  to  the 
area  of  suppuration  increases  the  hectic  fever.  Deposits  in  the  brain 
cause  delirium  and  stupor,  but,  without  these,  low-muttering  delirium 
comes  on,  with  a  typhoid  state,  and  death  occurs  in  a  gradually  deep- 
ening coma.  The  fatal  result  may  occur  in  one  week,  or  may  be  post- 
poned to  six  weeks — the  average  being  about  three. 

The  diagnosis  must  always  be  a  matter  of  extreme  difficulty,  and 
can,  indeed,  be  made  only  when  the  cause  is  clear  and  all  the  symp- 
toms appear  in  their  proper  relation.  It  will  be  impossible  in  any 
doubtful  case  to  differentiate  between  pylephlebitis  and  abscess  of  the 
liver. 

The  treatment  is  without  utility.  While  this  is  true,  it  is  certain, 
however,  that  much  may  be  done  to  relieve  pain  by  the  hypodermatic 
injection  of  morphia.  It  is  in  a  high  degree  probable  that  large  doses 
of  quinia  may  be  very  serviceable  in  checking  suppuration,  and  the 
free  use  of  alcohol  is  certainly  applicable  in  the  same  direction.  The 
combination  of  morphia  and  quinia,  with  the  conjoined  administration 
of  alcoholic  stimulants,  offers  the  best  prospect  of  relief. 


DISEASES    OF    THE    BILIARY    PASSAGES:     CATARRH    OP    THE 

BILE-DUCTS. 

Definition. — By  catarrh  of  the  bile-ducts  is  meant  an  inflammation 
of  the  mucous  membrane,  with  an  increased  production  of  mucus. 
Very  rarely  there  occurs  a  croupous  inflammation,  associated  with 
infectious  maladies,  as  pysemia,  diphtheria,  etc. 

Cause. — Catarrh  of  the  biliary  passages  may  arise  spontaneously 
from  climatic  causes  or  from  malarial  influence.  It  occurs,  therefore, 
more  frequently  in  the  autumn,  when  cool  nights  succeed  to  warm 
days,  and  when  malaria  is  most  rife.  Malaria  may  induce  jaundice 
by  catarrhal  swelling  of  the  bile-ducts,  without  any  febrile  disturb- 
ance.* Catarrh  of  the  bile-ducts  is  usually  a  secondary  disease,  sec- 
ondary to  duodenal  or  gastro-intestinal  catarrh,  which  extends  by  con- 
tinuity of  tissue  up  the  bile-ducts.  A  variety  of  causes  are  concerned 
in  the  production  of  duodenal  catarrh — notably,  excesses  in  eating  and 
drinking.  Usually  the  attacks  are  excited  by  some  article  of  food 
which  especially  disagrees,  but  a  catarrhal  state  of  a  chronic  kind  has 
preceded  the  acute  attack. 

Pathological  Anatomy. — More  or  less  extensive  hyperemia  is  the 
initial  lesion.  The  common  duct  is  more  affected  than  any  other  part 
of  the  canal-system,  but  the  catarrhal  process  may  extend  to  and  in- 
volve the  canaliculi.  The  mucosa  is  swollen,  the  more  decidedly  near 
the  duodenum,  and  is  coated  with  a  tenacious  mucus,  so  that  the 

*  "  De3  Affections  Paludeennes  du  Foie,"  par  MM.  A.  Kelsch  et  P;  L.  Kiener,  "  Arch. 
de  Physiologie  normale  et  pathologique,"  1878,  p.  571,  et  seq. 


CATARRH   OF   THE   BILE-DUCTS.  Igj 

lumen  is  much  narrowed  or  obstructed.  The  mucous  secretion  of  the 
gall-bladder  is  increased  in  amount  and  mixed  with  the  bile,  stored  up 
more  abundantly  because  the  obstruction  at  the  outlet  existed  while 
the  hepatic  and  cystic  ducts  were  still  pervious.  The  viscid  mucus 
and  sero-mucus  poured  out  from  the  surface  of  the  membrane  contain 
cast-off  epithelium,  abundant  nuclei,  and  white  corpuscles,  and  the 
endothelium  itself  undergoes  proliferation.  The  obstruction  below 
preventing  the  escape  of  bile,  and  the  mucus  and  sero-mucus  accumu- 
lating by  continued  production,  the  ducts  above  become  dilated,  and 
the  tissue  of  the  liver  presents  the  usual  appearance  of  bile-staining 
when  there  is  a  biliary  stasis.  After  several  days  the  hypersemia  less- 
ens, and  a  quantity  of  dead  endothelium  is  cast  off,  still  more  effectu- 
ally blocking  the  passage  ;  but  the  contents  of  the  bile-ducts  gradually 
liquefy,  and  the  lumen  is  restored  to  its  former  dimensions  by  the 
escape  of  these  matters  into  the  duodenum.  Th  e  whole  process  will 
occupy  several  weeks.  This  fortunate  solution  of  the  catarrhal  process 
is  not  always  effected.  The  soft  tissue  of  the  liver-parenchyma  is  ex- 
ceedingly liable  to  degenerative  changes.  Recent  researches  (Charcot,* 
Legg  f )  have  demonstrated  that  mere  mechanical  blocking  of  the  com- 
mon duct  leads  in  a  short  time  to  fibroid  degeneration  (increase  of  the 
connective  tissue,  interstitial  hepatitis)  and  atrophy  of  the  gland-cells. 
It  has  long  been  known  that  persistent  attacks  of  catarrh,  or  the  fre- 
quent repetition  of  them,  will  lead  to  changes  in  the  parenchyma  ; 
but  these  late  investigations,  by  demonstrating  the  readiness  with 
which  pathological  alterations  occur  in  the  hepatic  parenchyma,  have 
added  much  to  the  pathogenetic  importance  of  catarrh  of  the  bile- 
ducts.  Rarely,  isolated  portions  of  the  liver  remain  obstructed,  and 
dilated  duets,  surrounded  by  parenchyma  deeply  stained  with  bile  and 
much  altered,  exist  in  patches  throughout  the  organ. 

Symptoms. — The  signs  and  symptoms  indicating  the  onset  of  the 
malady  are  not  the  same  for  all  forms.  The  form  due  to  alternations 
of  temperature  at  certain  seasons  commences  abruptly  with  some  pain, 
soreness,  and  sense  of  weight  in  the  right  hypochondrium  ;  constipa- 
tion exists,  the  tongue  is  coated,  and  the  appetite  absent ;  and  there 
are  some  feverishness  and  general  malaise.  There  are  also  much  de- 
pression of  spirits  and  a  feeling  of  illness,  greater  than  the  actual  lesions 
warrant.  In  from  three  to  five  days  the  eyes  become  yellow,  and 
icterus,  or  jaundice,  then  gradually  appears  over  the  whole  body. 
Usually  the  fever  disappears  in  two  or  three  days,  the  skin  becomes 
dry  and  harsh,  and  the  surface  cold.  The  pulse  is  slow,  the  action  of 
the  heart  weak,  and  the  strength  depressed.     When  this  form  of  jaun- 

*  "Legons  sur  les  Maladies  du  Foie,  des  Voies  Biliaires  et  des  Reins,"  Paris,  18'7'7, 
p.  354. 

f  " St,  Bartholomew's  Hospital  Reports,"  vol.  ix ;  various  articles  in  the  "British 
Medical  Journal,"  etc. 


182  DISEASES   OF  THE   LIVER, 

dice  is  produced  by  malarial  infection,  the  symptoms  will  develop 
more  slowly,  unless,  indeed,  the  disturbance  in  the  hepatic  functions 
is  accompanied  by  malarial  fever — intermittent  or  remittent.  The 
most  usual  determining  cause  of  catarrhal  jaundice  is  gastro-intesti- 
nal,  especially  duodenal,  catarrh.  In  some  subjects  a  chronic  catarrh 
exists,  and  but  little  additional  disturbance  sufGlces  to  close  the  duct. 
In  others  an  acute  catarrh  is  brought  on  by  some  indigestible  food  or 
improper  drink.  In  either  case,  the  patient  experiences  a  good  deal  of 
nausea,  has  a  heavily  coated  tongue,  headache,  and  a  somewhat  muddy 
complexion,  and  there  may  be  more  or  less  fever,  or  none  at  all.  The 
jaundice  does  not  appear  at  once  ;  there  must  be  sufficient  time  for  the 
extension  to  the  bile-ducts  to  take  place,  which  will  require  from  one 
to  two  weeks.  The  bile-pigment  tints  all  the  tissues  of  the  body,  the 
secretions,  and  even  pathological  products,  as  effusions  into  the  ven- 
tricles and  thoracic  cavity.  The  urine  soon  assumes  a  brownish  color, 
like  that  of  port  or  black  coffee,  and  is  heavily  loaded  with  urates. 
Some  drops  of  the  urine  placed  on  a  white  porcelain  surface,  and  a 
little  nitric  acid  made  to  flow  against  it,  will  exhibit  the  following  re- 
action at  the  margin  where  the  two  fluids  come  in  contact :  a  greenish 
tint,  quickly  followed  by  blue,  violet,  to  red.  This  play  of  colors  may 
not  be  seen,  but  bilirubin,  where  touched  by  nitric  acid,  should  take 
on  a  greenish  hue,  being  converted  to  biliverdin.  During  the  febrile 
stage,  if  fever  has  existed  at  all,  the  pulse  rises  ;  but  when  jaundice 
appears,  if  no  fever  is  present,  the  action  of  the  heart  is  slowed  and 
the  tension  of  the  vascular  system  lowered.  The  pulsations  may  de- 
cline so  much  as  twenty  or  thirty  to  the  minute.  This  dej)ression  of 
the  circulation  is  due  to  the  action  of  the  biliary  salts  on  the  heart 
itself,  for  the  same  effect  is  produced  when  the  pneumogastric  has 
been  previously  divided.  No  bile  passing  into  the  intestine,  certain 
substances  fail  to  be  digested,  especially  the  fats,  and  the  foods  pres- 
ent there  decompose,  and  a  great  quantity  of  fetid  gas  is  formed. 
The  results,  then,  of  the  absence  of  bile  are  white,  pasty,  or  grayish- 
white,  or  gray,  slate-colored  stools,  having  a  very  offensive  smell,  and 
flatulence.  The  presence  of  bile  in  the  skin  excites  in  most  persons  a 
great  deal  of  unpleasant  itching,  which  may,  indeed,  be  troublesome 
enough  to  prevent  sleep.  The  vision  is  yellow  from  the  presence  of 
bile-pigment  in  the  humors  of  the  eye.  The  liver  increases  in  size, 
and  extends  a  little  beyond  the  margin  of  the  ribs,  and  the  gall-blad- 
der is  also  sufiiciently  distended  to  be  felt,  in  thin  persons,  projecting 
beyond  the  margin  of  the  liver,  or  be  made  out  by  careful  percussion. 
If  the  gall-bladder  partakes  in  the  inflammation,  it  becomes  tender. 
Usually  in  from  two  to  five  days  after  the  jaundice  appears,  the  un. 
pleasant  symptoms  subside — the  fever  ceases,  the  tongue  cleans,  and 
the  appetite  returns,  and  only  the  jaundice  and  the  torj)id  state  of  the 
intestines  remain.     In  a  few  days  the  stools  become  darker  and  then 


CATARRH   OF   THE   BILE-DUCTS.  183 

normal,  the  fetid  odor  disappearing  at  the  same  time.  The  coloration 
of  the  tissues  and  the  pigment  in  the  urine  continue  until  the  work 
of  elimination  is  complete,  and  hence  high-colored  urine  is  the  final 
symptom. 

Course,  Duration,  and  Termination. — Cases  pursuing  the  ordinary- 
course,  having  the  catarrhal  period,  the  jaundice  j^eriod,  and  the 
period  of  convalescence,  last  from  three  to  six  weeks,  and  terminate 
in  complete  recovery.  Not  all  cases  pursue  this  favorable  course. 
The  resolution  may  be  postponed,  and  the  case  assume  a  chronic  char- 
acter, leading  to  changes  in  the  hepatic  parenchyma,  consisting  in 
increase  of  the  connective  tissue  and  an  atrophy,  largely  fatty,  of  the 
hepatic  cells.  The  existence  of  a  chronic  catarrh  of  the  duodenum 
invites  attacks  of  acute  catarrh  involving  the  ducts,  the  result  being 
the  same — changes  in  the  hepatic  parenchyma.  Catarrh  of  the  bile- 
ducts  becomes  much  more  important  from  this  point  of  view. 

Diagnosis. — At  the  beginning,  catarrh  of  the  biliary  passages  may 
be  confounded  with  the  initial  symptoms  of  acute  yellow  atrophy,  but 
the  sex  and  the  condition  of  pregnancy  are  so  influential  in  causing 
the  latter  that  we  have  in  these  etiological  factors  means  of  differ- 
entiating in  two  thirds  of  the  cases.  The  subsequent  behavior  of  the 
two  maladies  differs  so  widely  as  to  eliminate  all  doubt.  When  the 
jaundice  appears  there  is  a  possibility  of  confounding  it  with  the  jaun- 
dice which  sometimes  comes  on  in  the  course  of  cirrhosis  and  cancer, 
but  an  attentive  examination  of  the  history  of  each,  and  their  course, 
will  prevent  error. 

Treatment. — This  is  one  of  the  very  few  conditions  in  which  mer- 
curials may  be  prescribed  in  hepatic  diseases,  not  with  the  view  to 
increase  the  outflow  of  bile,  but  to  allay  irritation  of  the  mucous  mem- 
brane. From  y*^  to  -i-  grain  of  calomel,  rubbed  up  with  a  little  sugar, 
may  be  administered  every  four  hours  for  a  few  days.  Simultaneously, 
whether  malaria  is  or  is  not  an  element  in  the  case,  two  antipyretic 
doses  of  quinia  (10 — 15  grains)  should  be  given  daily  until  jaundice 
appears,  and  for  a  few  days  subsequently  to  its  full  development.  To 
maintain  free  action  of  the  kidneys  by  salines  is  highly  useful  by  favor- 
ing elimination.  The  ordinary  effervescing  powder,  or  the  aperient 
effervescing  powder,  if  constipation  is  decided,  is  well  adapted  to  ac- 
complish the  object.  The  Saratoga  waters,  or  Vichy,  or  Kissengen, 
or  Carlsbad,  may  be  drunk  freely  to  accomplish  the  same  purpose. 
In  the  chronic  cases,  with  persistent  plugging  of  the  bile-ducts,  which 
means  also  persistent  jaundice,  the  most  effective  remedy  is  sodium 
phosphate  in  3  j  doses  ter  in  die,  and  kept  up  until  the  jaundice  de- 
clines. This  is  also  the  most  appropriate  and  effective  remedy  in 
those  cases  of  chronic  gastro-duodenal  catarrh  with  occasional  at- 
tacks of  catarrhal  jaundice.  Recent  experimental  (Rutherford)  and 
clinical   experience  has  shown  the  value  of  euonymin  and  iridin  as 


184  DISEASES  OF  THE   LIVER. 

cholagogues.  Two  grains  of  the  former  and  four  of  the  latter,  given 
at  night,  and  followed  by  a  saline,  afford  excellent  results.  The  min- 
eral acids  were  formerly  held  in  great  esteem  in  the  treatment  of  these 
hepatic  affections,  but  it  is  now  known  that  alkalies  are  more  service- 
able. The  local  application  of  the  acid-bath  to  the  right  hypochon- 
drium  is  an  excellent  counter-irritant,  but  the  difficulty  experienced 
in  preventing  injury  to  the  clothing  is  a  strong  objection  to  its  use- 
Careful  regulation  of  the  diet  is  most  necessary.  Solid  food  should 
be  withdrawn  for  the  time  being,  and  all  fatty,  saccharine,  and  starchy 
substances  also,  for  these  require  the  action  of  the  bile  either  for  their 
solution  and  absorption,  or  to  prevent  their  decomposition.  The  most 
suitable  aliments  are  skimmed  milk  and  beef -juice.  The  former  should 
be  given  freely  every  three  hours,  and,  if  the  stomach  is  irritable,  a 
little  lime-water  should  be  added.  The  utility  of  the  milk  is  twofold 
— as  an  aliment  and  as  a  diuretic,  Bitartrate-of-potassium  lemonade 
is  an  excellent  diuretic  in  these  cases  to  remove  the  last  staining  of  the 
bile.  As  the  catarrhal  inflammation  subsides,  the  diet  may  be  increased 
but  it  should  consist  of  milk,  eggs,  fresh  meat,  fresh  fish,  and  the  suc- 
culent vegetables. 

OCCLUSION  OF    THE   BILIARY  PASSAGES. 

Causes. — The  pressure  of  tumors,  as  cancer  of  the  pancreas,  aneurism 
of  the  hepatic  artery,  etc.,  is  an  exterior  cause  ;  the  impaction  of  a  cal- 
culus, adhesion  of  opposed  surfaces  in  exudative  inflammation,  etc.,  are 
internal  causes  of  occlusion  of  the  bile-ducts, 

Eesults  of  Occlusion. — The  mucus  formed  all  along  the  canals  con- 
tributes somewhat  to  the  accumulation  of  fluids  when  the  outlet  is 
closed,  but  the  chief  constituent  is  bile.  The  neck  of  the  gall-bladder 
is  not  unfrequently  closed  by  an  impacted  calculus,  the  sac  becoming 
enormously  distended  with  a  transparent,  faintly  greenish  fluid,  result- 
ing from  the  transformation  of  the  mucus  and  of  the  bile  stored  up 
before  occlusion.  The  author  has  seen  one  example  of  occluded  orifice 
of  the  cystic  duct,  in  which  the  contents  of  the  gall-bladder  consisted 
of  forty-four  biliary  calculi  without  any  fluid.  As  the  gall-bladder  is 
an  organ  of  convenience  and  not  of  necessity,  its  closure  does  not  dis- 
turb the  hepatic  functions.  It  forms  sometimes — for  the  secretion  oi 
mucus  continues — a  tumor  of  considerable  size,  and  pyriform  shape, 
which  may  be  felt  projecting  from  under  the  liver.  Occlusion  of  the 
common  duct  (ductus  choledochus)  or  of  the  hepatic  duct  leads  to  dila- 
tation of  the  biliary  passages  and  to  changes  in  the  structure  of  the 
liver.  The  whole  organ  is  at  first  enlarged,  but  it  subsequently  under- 
goes atrophy  by  the  pressure,  and  death  ultimately  ensues  from  the 
blood-poisoning. 


BILIARY  CALCULI.  185 

BILIARY   CALCULI   (CHOLELITHIASIS— GALL-STONES). 

Causes. — In  the  normal  state  the  bile  does  not  contain  any  solid 
constituents.  The  formation  of  calculi  or  concretions  is  determined 
by  the  precipitation  of  a  crystallizable  substance  from  the  bile — choles- 
terine — which  is  held  in  solution  by  glycocholate  of  soda.  The  mucus 
formed  in  catarrh  of  the  biliary  passages  effects  a  decomposition  of 
this  compound.  It  is  probable  that  this  result  is  promoted  by  changes 
in  the  composition  of  the  bile,  and  that  the  cholesterine  may  be  in 
excess,  and  hence  held  feebly  in  its  combination.  Calculi  form  more 
frequently  after  than  before  the  middle  period  of  life,  for  then  choles- 
terine becomes  more  abundant ;  and  they  are  encountered  in  the  obese, 
in  hearty  feeders  by  preference,  and  in  the  sedentary.  Females  are 
more  liable  than  males,  especially  fat  women  who  eat  rich  food  and 
take  no  exercise. 

Pathological  Anatomy. — Cholesterine  is  the  principal  constituent 
of  biliary  calculi,  and  exists  in  the  crystalline  form  chiefly.  The  ac- 
tual proportion  of  this  constituent  to  the  others  is  from  seventy  to 
eighty  per  cent.  More  or  less  bile-pigment  enters  into  their  formation  ; 
also  the  carbonate  of  lime  and  earthy  phosphates  and  carbonates  ;  and 
a  particle  of  mucus  or  some  foreign  body  is  the  nucleus  about  which 
the  other  materials  crystallize  or  aggregate.  Occasionally  there  is 
a  single  concretion  of  large  size,  which  fills  the  gall-bladder,  but  usually 
they  are  very  numerous — sometimes  amounting  to  five  or  six  hundred. 
When  there  is  a  single  gall-stone  it  is  ovoid  or  globular,  to  adapt  it  to 
the  shape  of  the  sac,  but,  when  there  are  several,  they  assume  the  octa- 
hedral shape,  with  smooth  facets.  They  do  not  always  assume  regular 
shapes  :  some  are  covered  with  warty  masses  ;  others  are  leaf-shaped, 
etc.  In  color  they  are  brownish  or  yellowish-brown,  but  in  exceptional 
instances  are  found  in  all  colors  from  white  to  black.  They  are  very 
light,  the  specific  gravity  varying  from  1-500  to  1-800.*  Gall-stones 
usually  contain  a  nucleus,  composed  for  the  most  part  of  mucus, 
and  cholesterine  and  bile-pigments  are  deposited  in  alternating,  con- 
centric layers  around  it.  The  nucleus  is  not  always  in  the  center, 
and  there  may  be  several  nuclei,  and  hence  the  arrangement  of  the 
layers  is  irregular,  and  there  may  be  deposits  of  earthy  matter  and 
pigment,  without  cholesterine,  etc.  Gall-stones  may  be  found  in  any 
part  of  the  biliary  passages.  They  are  rare  in  the  interior  of  the  liver, 
and  they  are  not  often  found  in  the  hepatic  duct,  because  of  the  in- 
creasing caliber  below,  but  are  found  usually  and  in  the  largest  num- 
bers in  the  gall-bladder.  By  pressure  the  walls  are  irritated  and  a 
catarrh  is  set  up,  and  also  ulcerations  of  the  mucous  membrane  of  con- 
siderable depth  and  extent  are  induced.    The  walls  of  the  gall-bladder, 

*  Thudichum  on  "  Gall-stones,"  p.  10. 


186  DISEASES   OF   THE   LIVER. 

excited  to  frequent  expulsive  efforts,  undergo  hypertrophy,  and  the  mu- 
cous membrane  becomes  reticulated.  Inflammation  of  the  peritoneal 
investment  is  excited,  and  the  remains  of  exudations  and  adhesions  are 
usually  found.  Not  unfrequently  the  mouth  of  the  gall-bladder  is  oc- 
cluded by  an  impacted  calculus,  or  permanently  closed  by  inflamma- 
tory adhesions.  The  gall-stones  may  be  forced  down,  producing  pains 
in  the  passage  through  the  cystic  duct,  or,  the  mouth  of  the  gall-blad- 
der being  closed,  they  remain  and  produce  no  further  mischief.  Gall- 
stones may  become  impacted  in  the  cystic,  hepatic,  or  common  duct ; 
inflammation  and  ulceration,  with  perforation,  result. 

Symptoms. — When  gall-stones  are  free  in  the  biliary  passages  with- 
out obstructing  them,  they  give  rise  to  some  pain  in  the  right  hypo- 
chondrium  of  an  intennittent  character,  and  pains  radiating  thence  to 
the  shoulder,  umbilicus,  lumbar  region,  etc.  There  is  present  usually 
nausea,  even  vomiting,  and  there  may  be  chills,  followed  by  fever  and 
sweats.  These  symptoms  are  due  to  the  irritation  of  the  ducts,  without 
their  occlusion.  If  concretions  are  impacted  in  the  hepatic  duct,  there 
are  pains,  jaundice,  and  enlargement  of  the  liver.  When  calculi  escape 
from  the  gall-bladder  into  the  cystic  duct,  if  of  sufficient  size  to  irritate 
the  mucous  membrane  and  excite  spasm,  the  phenomena  of  hepatic  colic 
ensue.  Sometimes,  after  a  fit  of  anger,  or  the  receij)t  of  evil  tidings,  but 
most  frequently  in  about  three  hours  after  a  meal,  a  pain  of  exceeding 
violence  is  suddenly  felt  at  the  margin  of  the  liver  and  in  the  right  por- 
tion of  the  epigastric  region.  The  pain  has  a  boring,  burning,  lanci- 
nating character,  and  radiates  through  the  abdomen  and  chest  and  into 
the  shoulders  and  back,  but  the  situation  of  the  greatest  anguish  is  in 
the  region  of  the  gall-bladder.  The  pain  is  so  atrocious  that  the 
patient  writhes  with  the  agony,  rushes  up  and  down  the  room,  or  tosses 
from  side  to  side  if  in  bed.  The  surface  is  cold  and  covered  with  a 
cold  sweat,  and  often  a  severe  rigor  occurs  simultaneously.  There 
may  be  clonic  spasms  affecting  the  right  side,  or  an  epileptiform  seiz- 
ure, with  loss  of  consciousness,  may  occur.  Intense  nausea  accompanies 
the  pain.  At  first  the  food  is  thrown  up,  but  presently,  after  repeated 
retching,  only  some  mucus,  acid  and  watery  ;  but  the  vomiting  affords 
no  relief.  The  action  of  the  heart  is  feeble,  and  the  circulation  is  cor- 
respondingly depressed.  The  severity  of  the  seizure  is  influenced  by  a 
variety  of  circumstances — by  the  size  and  roughness  of  the  concretion, 
by  the  length  of  canal  to  be  traversed,  and  by  the'  condition  of  the 
nervous  system.  The  duration  of  the  seizure  varies  from  a  few  hours 
to  several  days,  and  the  first  attack  is  apt  to  be  more  severe  than  any 
succeeding  one.  When  the  attack  continues  for  several  days,  the  pain 
does  not  always  persist  even  for  hours,  for  there  are  remissions  in  which 
only  an  acute  soreness  remains,  and  the  exacerbations  behave  as  regular 
attacks.  It  is  highly  probable  that  in  these  cases  several  concretions 
are  passed  in  succession.     Again,  when  the  calculus  passes  from  the 


BILIARY   CALCULI.  187 

cystic  to  the  common  duct,  tliere  is  a  feeling  of  relief,  but  a  new  par- 
oxysm occui's  when  the  calculus  becomes  engaged  in  the  duodenal  ori- 
fice of  the  ductus  choledochus.  Inflammation  in  the  peritoneum  may 
be  excited  about  the  site  of  impaction,  and  involve  the  neighboring 
structures,  or  the  duct  may  become  gangrenous.  The  calculus,  by 
preventing  the  outflow  of  bile  in  the  hepatic  or  common  duct,  causes 
jaundice,  which  is  not  a  usual  symptom  in  impaction  of  the  cystic  duct ; 
although  it  may  be  present,  the  surrounding  swelling  being  sufficient 
to  prevent  the  flow  of  bile  through  the  common  duct,  or  it  is  probable 
that  jaundice  may  be  due  to  the  disturbance  in  the  hepatic  plexus  of 
nerves.  The  pain  suddenly  ceases  sometimes  by  the  dropping  of  the 
concretion  into  the  duodenum.  Jaundice  usually  succeeds  to  the  pain, 
and  is  not  often  seen  during  the  time  of  greatest  suffering.  Sometimes 
a  calculus  will  remain  impacted  in  the  common  duct  for  weeks  or  even 
months  ;  jaundice  persists,  the  bile  accumulates,  the  ducts  dilate,  until 
suddenly  the  impaction  is  overcome,  and  violent  bilious  vomiting  and 
diarrhoea  announce  the  delivery.  When  the  concretion  remains  per- 
manently impacted,  the  liver  undergoes  the  changes  already  noted  ;  the 
connective  tissue  multiplies,  the  gland-cells  waste  and  undergo  fatty 
metamorphosis,  and  the  organ  shrinks  in  size  (Charcot).  Careful  search 
should  always  be  made  in  the  evacuations  for  the  calculus.  The  fseces 
should  be  thoroughly  mixed  with  water,  the  solid  particles  allowed  to 
subside  and  the  fluid  portion  poured  off,  and  this  operation  must  be 
repeated  until  the  last  solid  parts  are  reached.  Sometimes — most 
frequently,  j^robably — there  is  but  one  calculus,  but  there  may  be  a 
hundred.  A  marvelous  change  takes  place  in  the  patient  as  soon  as 
the  calculus  reaches  the  intestine.  The  pain  ceases,  as  well  as  the  nau- 
sea and  vomiting,  the  bowels  act  spontaneously,  the  appetite  returns, 
the  jaundice  soon  disappears,  and  the  state  of  health  is  fully  restored. 
Course,  Duration,  and  Termination. — From  the  initial  pain  to  the 
termination  of  all  symptoms  may  not  be  longer  than  two  days,  or,  if 
jaundice  is  present,  five  days.  If  a  number  of  calculi  pass,  the  duration 
of  a  case  is  indefinitely  prolonged.  The  severe  cases  of  this  kind  last 
several  weeks.  The  usual  termination  is  in  health,  but  death  from 
ulcerative  perforation  and  subsequent  peritonitis  is  not  uncommon. 
Now  and  then  a  calculus  ulcerates  through  the  duct ;  in  the  peritonitis 
which  follows,  adhesions  are  formed,  limiting  the  mischief  to  the  im- 
mediate neighborhood  ;  a  purulent  depot  is  thus  created,  and  gradually 
a  fistulous  communication  externally  is  established,  and  the  calculus 
is  discharged  with  the  pus.  Sometimes  such  a  purulent  depot  opens 
communication  with  the  intestine,  stomach,  or  bladder.  The  last- 
named  terminates  fatally  ;  the  discharge  by  the  stomach,  intestine,  and 
externally  is  often  successful.  After  the  calculus  reaches  the  intestinal 
canal,  it  may  serve  as  a  source  of  new  mischief  by  forming  the  nucleus 
of  an  impaction  of  the  bowel. 


188  DISEASES  OF  THE    LIVER. 

Diagnosis. — The  only  maladies  with  which  hepatic  colic  may  be 
confounded  are  hej)atalgia,  gastralgia,  and  enteralgia.  The  locality  of 
the  pain,  the  absence  of  local  soreness,  the  absence  of  jaundice,  the 
absence  of  calculi  in  the  stools,  separate  these  neuralgic  affections  from 
hepatic  colic. 

Prognosis. — A  favorable  opinion  may  be  expressed  in  most  cases, 
but  the  prognosis  must  be  guarded  when  the  pain  does  not  yield,  and 
when  the  vital  powers  begin  to  flag,  especially  if  local  tenderness  and 
fever  indicate  peritonitis. 

Treatment. — The  severe  pain  demands  immediate  attention.  There 
are  two  methods  of  relieving  it :  by  the  inhalation  of  ether,  and  by 
the  hypodermatic  injection  of  morphia.  The  action  of  the  former  is 
temporary,  and,  of  course,  the  relief  is  confined  to  the  period  of  un- 
consciousness. This  may  be  sufficient,  but  usually  prolonged  adminis- 
tration is  necessary.  The  hypodermatic  injection  is  more  effective. 
From  -jig^  to  ^  of  a  grain  of  morphia  is  usually  sufficient  for  an  ordinary 
case,  but,  if  the  suffering  be  very  great,  J  to  |  grain  of  morphia  may 
be  required.  The  combination  of  morphia  and  atropia  is  both  more 
effective  and  safer,  and  hence  atropia  should  be  given,  j^  grain  at 
each  injection.  Not  only  does  this  remedy  remove  the  pain,  but  it  is 
the  most  efficient  means  of  preventing  or  subduing  peritoneal  inflam- 
mation. Anodynes  can  not  be  given  by  the  stomach  ;  anodyne  ene- 
mata  are  insufficient  in  this  malady — so  that  the  choice  of  remedies  is 
much  restricted.  Five  minims  of  chloroform  every  half  hour,  in  an 
emulsion  or  dropped  on  sugar,  has  been  proposed,  but  in  the  author's 
experience  it  is  usually  rejected,  and  excites  nausea  even  by  its  odor. 
It  has  been  gravely  proposed  to  administer  it  as  a  solvent  of  gall-stones, 
and  to  relieve  the  suffering  by  effecting  a  solution  of  the  impacted 
calculus.  Trousseau  had,  it  was  supposed,  disposed  of  this  notion,  but 
it  has  been  revived  again.  Chloral  has  also  been  employed  to  relieve 
the  pain,  but  it  has  not  much  anodyne  power,  and  is  besides  very  of- 
fensive to  the  stomach  in  these  cases.  Warm  baths  and  hot  fomenta- 
tions to  the  right  hypochondrium  contribute  to  relief.  Undoubted 
advantage  is  derived  from  the  use  of  leeches,  when,  the  symptoms 
persisting,  tenderness  develops  and  fever  arises. 

Prophylaxis  is  highly  important.  The  author  has  had  abundant 
and  highly  favorable  experience  with  the  plan  which  is  about  to  be 
recommended,  and  he  therefore  urges  it  on  the  attention  of  his  readers: 
The  diet  must  be  carefully  regulated.  All  fats  and  articles  containing 
fat  in  any  form  are  rigorously  excluded.  Saccharine  substances  are 
also  prohibited,  and  the  starchy  constituents  of  the  diet  are  reduced  to 
a  little  white  or  corn  bread — potatoes,  beans,  peas,  and  rice  being  ex- 
cluded. Lean  meat  of  all  kinds,  eggs,  fish,  fruit,  and  the  succulent 
vegetables  are  permitted  freely.  Wine  at  dinner  is  allowed,  but  malt 
liquors  and  spirits  are  forbidden.     Daily  exercise  is  directed.     All  ir- 


SPLENITIS.  189 

regularities  of  life  of  every  kind  are  given  up.  The  remedy  -whicli, 
above  all  others,  has  the  power  to  effect  the  solution  and  disposition 
of  calculi,  is  phosphate  of  soda.  This  is  prescribed  in  the  dose  of  a 
drachm  three  times  a  day,  dissolved  in  sufficient  water,  and  taken 
before  meals.  This  remedy  is  continued  for  several  weeks  or  months, 
and,  if  there  are  present  evidences  of  gastro-intestinal  catarrh,  jL  of  a 
grain  of  the  arseniate  of  soda  is  added  to  each  dose  of  the  phosphate. 
While  success  seems  always  to  attend  this  practice,  the  author  has 
been  constantly  disapjjointed  in  the  remedy  of  Durande  (ether  and 
turpentine),  and  in  the  administration  of  chloroform,  with  a  view  to 
its  solvent  action  on  retained  calculi.  As  the  catarrhal  state  of  the 
bile-ducts,  succeeding  to  catarrh  of  the  duodenum,  is  the  great  factor 
in  the  causation  of  gall-stones,  it  is  highly  important  to  correct  it. 
Without  attention  to  the  plan  of  diet  above  indicated  this  can  not  be 
accomplished  ;  but  the  persistent  use  of  phosphate  of  soda  can  do  much, 
even  without  a  change  in  the  habits  of  life,  toward  bringing  about  a 
cure.  Vichy-water,  and  our  own  Saratoga  Yichy,  as  well  as  the  alka- 
line waters  of  this  country,  which  are  so  abundant,  should  be  used  daily 
in  connection  with  the  plan  above  indicated.  Dr.  T.  H.  Buckler,  of 
Baltimore,  strongly  recommends  the  use  of  the  hydrated  succinate  of 
the  peroxide  of  iron  (  f  jss —  3  vjss  water — a  teaspoonful  ter  in  die)  as 
a  remedy  to  jDrevent  the  formation  of  calculL  The  use  of  this  remedy 
is  based  on  some  theoretical  notions  respecting  the  oxidizing  power  of 
succinic  acid  and  its  solvent  action.  Buckler  also  urges  the  use  of 
chloroform  during  the  paroxysms  of  colic,  as  a  solvent  of  cholesterine. 


DISEASES   OF   THE   SPLEEiSr. 


ACUTE   SPLENITIS. 

Definition. — By  the  term  acute  splenitis  is  meant  acute  inflamma- 
tion of  .the  spleen.  Perisplenitis  is  a  designation  apjDlied  to  inflamma- 
tion of  the  investing  tunic  or  capsule,  and  of  the  peritoneal  layer  of 
the  organ.  Acute  splenic  tumor  means  an  acute  enlargement — a  con- 
dition present  in  various  acute  infectious  diseases. 

Causes. — Our  present  knowledge  of  the  etiology  of  spleen-diseases 
is  very  unsatisfactory.  Hardly  anything  is  known  of  idiopathic  spleni- 
tis. Of  the  secondary,  or  metastatic  malady,  our  information,  if  not 
full,  at  least  contains  some  certain  data.     That  splenitis  arises  from 


190  DISEASES   OF   THE   SPLEEN. 

embolism  is  now  well  known.  Inflammation  of  neighboring  parts  ex- 
tends to  and  involves  the  spleen.  Direct  injury,  as  a  blow  over  the 
left  hyj)ochondrium,  may  excite  inflammation  in  the  spleen.  A  case 
arising  in  this  way  the  author  had  under  observation  during  life,  and 
was  present  at  the  autopsy ;  hence  the  account  given  of  the  disease 
in  question  is  derived  largely  from  this  experience. 

Pathological  Anatomy. — Local,  or  circumscribed,  splenitis  is  in- 
duced by  embolic  blocking  of  a  vessel  or  vessels,  and  hence  the  infarc- 
tions may  be  one,  or  two,  or  three  in  number  ;  they  may  be  in  the  sub- 
stance, or  at  the  periphery  of  the  organ.*  These  infarctions  vary  in 
size  from  a  pea  to  a  hen's-egg,  are  wedge-shaped,  and  when  near  to- 
gether may  coalesce.  These  infarctions  undergo  the  usual  transfor- 
mation, and  a  purulent  collection  is  the  ultimate  result  of  the  changes. 
A  limiting  membrane  may  form,  and  the  pus  become  encapsulated,  or 
the  boundaries  of  the  purulent  depot  may  be  constituted  of  the  rag- 
ged, disintegrating,  soft,  splenic  pulp.  The  pus  tends  to  make  its  way 
externally,  and  when  the  capsule  is  reached  adhesions  form,  usually  to 
the  diaphragm.  In  the  author's  case,  as  a  result  of  a  powerful  blow 
on  the  left  hypochondrium  (which,  however,  left  no  external  trace  of 
the  injury),  the  whole  organ  was  turned  into  a  brownish  purulent  col- 
lection of  eighteen  ounces'  capacity.  Adhesions  had  been  formed  with 
the  diaphragm,  which  was  softening,  and  adhesion  of  the  opposed 
pleural  surfaces  indicated  the  preparation  for  discharge  by  a  bronchus. 
The  abscess  may  break  into  the  peritoneal  cavity,  with  the  effect  of 
inducing  fatal  peritonitis. 

Symptoms. — As  the  systematic  writers  are  not  agreed  as  to  the 
character  of  the  symptomatology,  the  author  describes  it  wholly  from 
his  own  observation.  After  the  injury,  or  we  may  also  suppose  the 
embolic  obstruction,  in  a  day  or  two,  pain  is  experienced,  deeply  in 
the  right  hypochondrium.  The  sensation  is  rather  of  an  aching  char- 
acter, which  becomes  soreness  and  tenderness  when  the  organ  is  com- 
pressed— a  feat  that  is  accomplished  by  pressing  upward  under  the 
ribs  when  the  patient  takes  a  full  inspiration.  There  is  usually  pain 
developed  by  taking  a  deep  breath,  which  becomes  catching  and  acute 
when  the  peritoneum  is  invaded.  Neither  on  palpation  nor  on  per- 
cussion can  an  increase  in  the  volume  of  the  spleen  be  made  out  with 
certainty.  In  about  a  week  after  the  initial  symptoms,  a  rigor  oc- 
curred, followed  by  fever  and  sweats,  and  these  appeared  irregularly 
up  to  the  end.  The  face  was  pallid,  the  lips  white,  the  sclerotic  glis- 
tening, the  body  emaciated,  and  the  weakness  extreme.  The  appetite 
was  lost,  there  was  occasional  vomiting,  and  diarrhoea  supervened 
toward  the  termination  of  the  case.  Presently  a  harassing,  dry  cough, 
accompanied  with  pain  and  an  obstinate  hiccough,  made  its  appear- 

*  Billroth  ;  Virchow's  "  Archiv,"  Band  xxiii,  p.  473  :  "  Der  haemorrhagische  Infarkt 
und  seine  Metamorphosen." 


ENLARGEMENT   OF   THE  SPLEEN.  191 

ance.  An  increase  in  the  left  side  through  the  hypochondrium  and 
an  enlargement  of  the  area  of  splenic  dullness  now  became  evident. 
Death  occurred  by  exhaustion  on  the  forty-second  day  from  the  first 
symptoms. 

Course,  Duration,  and  Termination.— Nothing  can  be  more  ill-de- 
fined than  the  course  of  splenitis.  The  duration  of  cases  of  inflamma- 
tion terminating  in  abscess  may  be  not  more  than  a  month,  and  yet 
cases  have  continued  several  years  (Mosler).  Splenitis  may  terminate 
in  resolution  without  symptoms.  This  is  the  most  probable  explana- 
tion of  the  existence  of  cicatricial  depressions  on  the  surface  of  the 
spleen,  found  in  cases  dying  from  other  causes.  Cases  proceeding  to 
suppuration  terminate  by  discharge  through  the  lungs,  of  which  a 
successful  case  has  been  reported,  or  communication  is  established 
with  the  stomach,  the  transverse  colon,  the  left  kidney,  or  with  the 
general  cavity  of  the  abdomen. 

Diagnosis. — If  endocardial  lesions  exist,  and  sudden  pain  followed 
by  swelling  occur  in  the  splenic  region,  and  subsequently  there  arise 
the  usual  symptoms  of  suppuration,  or  if,  as  a  result  of  a  blow,  pain 
and  tenderness  and  swelling  develop  in  the  left  hypochondrium,  the 
spleen  may  be  presumed  to  be  the  seat  of  the  mischief. 

Prognosis. — As  those  cases  of  splenitis  which  terminate  in  recovery 
are  never  recognized,  the  question  of  prognosis  does  not  come  up  for 
solution.     "When  abscess  occurs,  the  prognosis  is  unfavorable. 

Treatment. — If  the  existence  of  splenitis,  from  any  cause,  is  as- 
certained, quinia  must  be  freely  administered,  and  cinchonism  main- 
tained. There  are  two  good  reasons  for  this  practice  :  quinia  checks 
the  migration  of  the  white  corpuscles  and  the  process  of  suppuration, 
and  lessens  hypergemia  of  the  spleen.  No  therapeutical  fact  is  better 
established  than  that  quinia  reduces  the  size  of  the  spleen  when  it  is 
enlarged  by  hyperemia.  Quinia  is,  therefore,  peculiarly  adapted  to 
the  treatment  of  splenitis.  Purgatives  act  on  the  spleen  in  two  modes  ; 
by  reflex  action,  and  by  diminishing  the  general  blood-pressure.  Sa- 
line cathartics  should  be  used  to  maintain  free  action  of  the  intestines. 
Warm  fomentations,  turpentine-stupes,  and  hot  jDOultices  should  be 
applied  over  the  left  hypochondrium.  If  suppuration  is  clearly  ascer- 
tained, the  aspirator  should  be  used  without  delay,  just  as  it  is  now 
employed  in  a  similar  state  of  things  in  the  liver.  The  strength  must 
be  kept  up  by  suitable  food  and  stimulants. 

ENLARGEMENT  OF  THE  SPLEEN.— Owing  to  its  peculiar  ana- 
tomical structure,  the  spleen  is  especially  liable  to  variations  in  size, 
strictly  within  physiological  limits.  In  the  acute  infectious  maladies 
the  organ  undergoes  a  change  in  size  of  a  pathological  character.  In 
typhus,  typhoid,  puerperal,  and  the  eruptive  fevers,  the  spleen  en- 
larges, but  in  the  fevers  of  raarsh-miasm  the  change  in  size  is  greater. 


192  DISEASES   OF   THE   SPLEEN. 

In  certain  parts  of  this  country — the  Wabash  Valley,  for  example — a 
splenic  tumor  of  extraordinary  size  (ague-cake)  sometimes  develops 
under  the  influence  of  malaria  without  the  objective  phenomena  of 
fever,  but  with  the  same  bodily  changes  as  occur  in  intermittent  and 
remittent  fevers.  Obstructive  diseases  of  the  heart,  lungs,  or  liver,  by 
causing  stasis  in  the  venous  system,  give  rise  to  enlargement  of  the 
spleen,  and  especially  does  this  result  follow  sclerosis,  and  acute  yel- 
low atrophy  of  the  liver.  In  the  condition  of  enlargement  which  occurs 
during  the  course  of  fevers — excepting  from  consideration  malarial 
fevers — the  spleen  is  excessively  soft,  the  splenic  pulp  almost  diffluent, 
the  capsule  and  trabeculse  easily  torn.  In  the  acute  enlargement  which 
accompanies  the  febrile  movement  of  malarial  fevers,  there  is  really  no 
alteration  of  structure — the  pulp  and  trabeculae  and  the  Malpighian 
bodies  having  their  normal  appearance  and  structure,  but  the  increase 
is  due  to  an  immense  venous  congestion.  On  the  other  hand,  in  the 
enlargement  which  occurs  without  fever,  or  produced  after  successive  at- 
tacks of  fever,  the  organ  is  dense,  firm,  and  paler,  due  to  the  great  devel- 
opment of  the  trabeculae  and  corresponding  diminution  of  the  splenic 
pulp.  In  these  cases  of  chronic  enlargement  due  to  malarial  infection, 
the  organ  may  attain  considerable  size,  greatly  distend  the  abdomen, 
and  reach  to  and  even  extend  beyond  the  umbilicus.  There  is  in 
these  cases  an  extreme  anaemia — a  pseudo-leukemia — the  superficial 
veins  of  the  abdomen  are  enlarged,  the  legs  are  swollen,  and  there  is 
some  effusion  in  the  abdomen — results  of  the  mechanical  pressure.  A 
splenic  tumor  of  medium  size,  formed  in  the  mode  above  indicated, 
may  lodge  on  the  aorta  and  be  confounded  with  aneurism. 

MISPLACEMENT   OF  THE   SPLEEN,  or  MOVABLE   SPLEEN.— 

Changes  in  the  position  of  the  spleen  are  effected  by  effusions  in  the 
left  thoracic  cavity,  which  displace  the  organ  downward.  When  en- 
larged and  in  the  condition  of  "fleshy  spleen"  above  described,  the 
spleen  may  descend  considerably  by  its  own  weight,  and  thus  seem 
more  enlarged  than  it  is  really.  The  movable  spleen,  like  the  movable 
kidney,  is  displaced  from  its  position,  and  its  vessels  with  the  omen- 
tum are  stretched  and  ultimately  assume  the  shape  of  a  pedicle — an 
irregularly  rounded  cord — of  which  the  author  has  seen  several  capital 
examples.  Such  a  spleen  may  be  moved  by  a  change  in  the  position  of 
the  patient,  or  by  palpation,  and  may  lie  across  the  abdominal  artery 
and  be  lifted  up  synchronously  with  the  arterial  pulsation,  or  be  dis- 
placed downward  into  the  iliac  fossa,  and  may  rotate  on  its  horizontal 
axis.  Changes  in  the  structure  of  the  organ  necessarily  occur  under 
these  circumstances  ;  the  blood-supply  is  lessened,  or  thromboses  form 
in  the  vessels  ;  there  are  shriveling  and  atrophy,  pigmentary  and  fatty 
degeneration,  etc. 


AMYLOID   SrLEEX.  193 

AMYLOID  DEGENERATION  OF  THE  SPLEEN.— Thi«  disease  con- 
sists in  the  deposits  of  the  amyloid  matter,  either  in  the  form  of  small 
patches,  forming  the  ^v^ell-known  "  sago-spleen,"  or  in  a  general  diffu- 
sion of  the  material  through  the  whole  organ.  In  the  former  the 
patches  may  be  very  numerous  and  almost  unite,  but  there  still  remains 
normal  spleen-tissue  between  them.  In  the  latter  form  the  texture  of 
the  spleen  is  firm  and  tough,  but  easily  divided  with  the  knife,  although 
not  readily  broken  up  into  a  pulp,  and  it  has  a  brownish  or  yellowish- 
brown  color,  and  no  part  remains  untouched  by  the  new  deposit — 
the  pulp,  the  trabeculge,  the  Malpighiau  bodies,  the  vessels,  all  are 
changed  in  structure  and  physical  properties  by  the  amyloid  matter. 
The  test  for  this  matter  is  iodine — Lugol's  solution — which  when 
brushed  over  colors  the  tissues  yellowish,  but  the  amyloid  matter  red 
or  reddish  brown  :  now,  on  the  addition  of  sulphuric  acid,  while  the 
yellowish  parts  remain  yellow,  the  amyloid  becomes  a  dark  violet. 
The  amyloid,  or  lardaceous,  or  waxy  degeneration  of  the  spleen 
occurs,  simultaneously  with  the  same  form  of  degeneration  in  the 
liver  and  intestinal  canal,  and  hence  the  symptomatology  is  rather 
that  of  the  disturbance  in  the  function  of  the  other  organs.  These 
symptoms  have  been  detailed  in  the  remarks  on  amyloid  liver.  The 
only  contribution  made  to  the  symptomatology  by  the  alterations  in 
the  spleen  are,  the  increased  area  of  splenic  dullness  and  a  greater 
degree  of  anaemia  and  pseudo-leukemia.  The  great  cause  of  amyloid 
degeneration  of  the  spleen  as  of  other  organs  is  suppuration,  espe- 
cially protracted  suj^puration  in  connection  with  bone.  Next  to  this 
are  the  syphilitic  cachexia  and  inherited  syphilis.  Chronic  alcoholism 
and  chronic  malarial  poisoning  are  supposed  to  have  some  influence  in 
its  production,  but  it  is  extremely  doubtful  whether  they  have  any  real 
influence. 

ECHINOCOCCUS  OF  THE  SPLEEN.— The  embryo  of  the  taenia 
echinococcus  is  deposited  in  the  spleen  as  in  other  organs,  and  more 
frequently  in  the  spleen  than  in  any,  except  probably  the  liver.  The 
liver  is  reached  readily  by  the  portal  vein,  and  the  spleen  directly,  as 
the  two  organs  come  into  contact.  When  established  in  its  home, 
growth  begins,  chiefly  by  the  development  of  daughter-vesicles  in  the 
mother-sac.  The  symptoms  produced  are  due  to  the  size  to  which  the 
sac  attains,  the  pressure  on  neighboring  organs,  and  the  interference 
with  the  circulation  in  the  great  vessels  of  the  abdomen.  The  slow- 
ness of  the  growth,  the  absence  of  constitutional  disturbance,  the  free- 
dom from  j^ain,  and  the  absence  of  symptoms  except  those  due  to  the 
size  of  the  tumor,  separate  the  echinococcus  from  other  tumors  of  the 
spleen.  The  sense  of  fluctuation,  and  especially  the  purring  ti'emor, 
serves  to  distinguish  this  from  hypertrophy  of  the  spleen.  The  employ- 
ment of  the  aspirator-needle  will  contribute  to  certainty  of  diagnosis, 
13 


194  DISEASES   OF   THE   BLOOD-FORMING   ORGANS. 

but  the  presence  of  booklets  and  the  absence  of  albumen  can  not 
always  be  depended  on,  for  the  booklets  may  be  absent,  and  albumen 
may  be  present  in  echinococcus  tumors  of  the  spleen.  For  further 
details  the  reader  is  referred  to  the  subject  of  echinococcus  of  the 
liver. 


DISEASES    OF    THE    BLOOD-FORMING    ORGANS. 


LEUCOOYTHEMIA— LPUO.EMIA. 

Definition. — The  terms  leucaemia  and  leucocythemia  were  proposed 
by  rival  claimants  for  priority  of  discovery — Virchow  and  Hughes 
Bennett.  The  term  leucocythemia,  proposed  by  Bennett,  seems  to  the 
author  a  more  correct  designation,  meaning  white-cell-hlood,  than  Vir- 
chow's  leucaemia,  which  means  vihite  blood.  The  morbid  change  which 
has  given  the  name  to  the  disease  is  the  enormous  increase  of  the  white 
corpuscles  of  the  blood,  accompanied  by  enlarged  spleen  and  enlarged 
lymphatic  glands,  and  by  alterations  in  the  marrow  of  bones.  By 
Trousseau  it  is  designated  adenie.  and  by  Griesinger  anaemia,  splenica. 

Causes. — The  excessive  production  of  leucocytes,  which  is  the  chief 
element  in  this  disease,  must  necessarily  be  due  to  a  functional  and 
nutritive  irritation  of  the  blood-making  organs.  The  evidence  of  this 
is  afforded  in  the  enlargement  of  the  spleen  and  lymphatic  glands. 
But  the  cause  of  this  remains  unknown,  and  hence  the  real  nature  of 
the  malady  continues  an  insoluble  problem.  Leucocythemia  occurs 
at  all  ages  and  under  every  kind  of  social  circumstance,  but  it  attacks 
by  preference  the  male  sex,  the  most  vigorous  period  of  life — thirty 
to  forty-five — and  those  who  have  been  weakened  by  hardships  and 
excesses.  Menstrual  irregularities  have  been  supposed  to  "have  an 
influence  in  developing  it,  and,  in  twenty-one  cases  of  this  disease  oc- 
curring in  women,  there  were  sixteen  in  whom  some  disorders  of  the 
uterus  had  existed  (Hosier).*  It  is  probable  that  these  sexual  irregu- 
larities were  rather  coincident  than  causal.  The  cachexise  of  chronic 
malarial  poisoning  and  of  syphilitic  infection  have  been  invoked  to 
account  for  its  production,  but  no  satisfactory  data  have  as  yet  been 
published,  although  there  are  examples  of  accidental  association.  Re- 
garded from  the  analogical  point  of  view,  leucocythemia  may  be 
classed  with  scrofula,  cancer,  tubercle,  and  other  infectious  diseases, 

*  Ziemssen's  "  Cyclopaedia,"  vol.  viii,  "  Diseases  of  the  Spleen." 


LEUCOCYTHEMIA.  195 

which,  beginning  at  one  point,  or  focus,  diffuse  thence  over  the  body. 
The  morbid  alterations  characteristic  of  this  disease  begin  in  the 
spleen,  then  attack  the  lymphatic  glands,  then  the  marrow  of  bones, 
and  thus  become  general. 

Morbid  Anatomy. — The  most  constant  lesion  is  in  the  spleen,  which 
is  increased  in  size,  either  uniformly,  its  form  and  shape  being  pre- 
served, or  some  part  of  the  organ  undergoes  the  change.  Not  only 
the  size  but  the  firmness  and  density  are  increased.  The  color  be- 
comes a  reddish  blue  ;  the  pulp  undergoes  hypertrophy,  but  the  nor- 
mal relations  of  its  elements  are  preserved  ;  the  trabecule  may  be 
more  distinct,  or  may  be  obscured  by  the  overgrown  pulp  ;  the  Mal- 
pighian  bodies  are  rather  increased  in  number,  very  distinct,  but  less 
consistent  than  normal.  The  trabeculae  and  pulp  may  be  coated  with 
a  yellowish,  fibrinous  exudation  ;  there  may  be  seen  white  granules 
disseminated  throughout  the  organ,  and  near  the  surface  patches  of 
indurated  tissue,  the  remains  of  hemorrhagic  infarctions.  The  change 
in  the  lymphatics  consists  in  an  initial  hyperaemia,  then  hyperplasia 
of  its  constituent  parts,  first  of  the  cellular  elements,  then  of  the  stro- 
ma and  vessels.  They  enlarge  in  proportion  to  the  addition  of  new 
material,  from  a  bird's  egg  to  a  goose-egg  or  larger.  They  have  a 
smooth,  rather  glistening,  appearance,  and  to  the  touch  are  soft,  non- 
elastic,  and  sometimes  fluctuating.  All  of  the  lymphatic  glands  in  the 
body  may  be  engaged,  or  the  process  may  be  confined  to  a  few. 
Usually  those  situated  about  the  hilus  of  the  liver  and  spleen  are  en- 
larged. Similar  changes  take  place  in  the  lymj)hatics  of  the  digestive 
tract,  beginning  in  the  follicles  of  the  tongue  and  tonsils,  of  the  stom- 
ach, and  in  the  glands  of  Peyer.  Corresponding  changes  occur  in  the 
marrow  of  long  bones,  and  in  the  cancellated  tissue  of  the  ribs  and 
sternum.  The  marrow  is  abundantly  infiltrated  with  lymphoid  cells, 
and  the  vascular  network  with  its  delicate  connective  tissue,  which 
exists  in  the  normal  condition,  disappears,  and  only  the  larger  arterial 
branches  remain.  The  result  is  that  the  marrow,  instead  of  its  rose- 
color,  becomes  yellowish  or  greenish  yellow.*  In  somewhat  more 
than  one  half  of  the  cases  the  liver  is  enlarged  and  changed  in  struc- 
ture by  reason  of  the  development  of  the  new  lymphadenoid  tissue  of 
the  organ.  It  increases  in  size,  sometimes  immensely  so,  and  weighs 
from  four  to  eighteen  pounds.  This  change  is  at  first  a  mere  prolifera- 
tion of  the  lymph-cells  ;  then  occurs  an  infiltration  of  lymph  new  for- 
mations, or  these  are  collected  in  masses  or  nodules,  like  tubercle.  The 
cells  penetrate  the  lobules  from  without  inward,  and  by  their  numbers 
dispossess  the  hepatic  cells,  which  atrophy  and  disappear,  only  spots 
of  pigment  remaining. f  The  most  important  change  is  that  which 
gives  the  name  to  the  disease,  the  increase  of  white  cells  in  the  blood. 

*  Mosler,  op.  cit. 

\  Rindfleisch,  "Pathological  Histology,"  pp.  183,  473,  American  edition. 


196  DISEASES   OF   THE   BLOOD-FORMING   ORGANS. 

The  gross  amount  of  blood  is  not  lessened,  but  its  specific  gravity  is 
reduced  from  1055  to  1040,  even  to  1035.*  The  color  is  paler  than 
normal,  and  purulent  looking.  The  proportion  of  white  corpuscles  is 
relatively  greatly  increased  ;  but  the  numbers  vary  from  one  to  ten, 
to  one  to  two  ;  indeed,  the  white  and  the  red  may  be  equal  in  num- 
bers ;  the  white  may  even  prejDonderate.  The  white  corpuscles  may 
differ  from  the  normal  in  being  larger  ;  in  sjDlenic  leucocythemia  they 
contain  one  or  several  nuclei ;  sometimes  the  cells  are  smaller,  and 
there  is  one  large  nucleus  ;  and  occasionally  transitional  forms  ai'e  dis- 
covered between  the  white  and  red,  such  as  are  found  in  the  cell- 
masses  of  the  marrows.  The  red  corpuscles  are  both  relatively  and 
absolutely  diminished  in  numbers,  the  water  and  fibrin  are  increased, 
the  iron  diminished,  and  certain  abnormal  ingredients  are  present,  as 
formic,  lactic,  and  acetic  acids,  hyj)oxanthin,  uric  acid,  leucin,  tyrosin  ; 
but,  of  these,  lactic  and  formic  acids  and  hypoxanthin  only  are  con- 
stantly present  (Mosler).  According  to  the  same  authority,  the  reac- 
tion of  the  blood  in  this  disease  is  not  acid,  but  alkaline.  The  morbid 
processes  of  leucocythemia  are  not  those  of  a  merely  splenic  disease — 
a  local  malady.  Hyperplasia  of  the  spleen  is,  however,  the  first  link 
in  the  chain  ;  from  this  organ,  immense  numbers  of  leucocytes  pour 
into  the  blood,  and  also,  it  is  probable,  some  products  of  the  splenic 
pulp,  as  lactic  and  formic  acid,  and  hypoxanthin,  etc.  ;  the  next  step 
consists  in  the  transplantation  and  subsequent  development  of  hetero- 
plastic materials  in  other  organs,  as  the  liver,  etc. 

Symptoms. — According  to  the  preponderance  of  the  leucsemic  pro- 
cess in  the  spleen,  lymphatics,  or  marrow  of  bones,  the  disease  is  en- 
titled splenic  leucocythemia,  lymphatic  leucocythemia,  and  myelogenic 
leucocythemia — for  these  organs  seem  equally  to  possess  the  power  of 
producing  white  corpuscles  and  introducing  them  into  the  blood,  and 
one  may  perform  the  ofiice  for  the  others.  When  the  spleen  is  re- 
moved there  are  very  few  defined  disturbances  of  the  functions,  as  the 
lymphatics  and  the  marrow  of  bone  perform  the  necessary  offices.  It 
is  the  siDlenic  form  of  the  disease  which  is  usually  encountered,  or  the 
splenic-lymphatic,  and  the  lymphatic  very  rarely,  and  the  myelogenic 
never.  The  development  of  leucocythemia  is  so  gradual  that  the  be- 
ginning of  symptoms  usually  passes  unnoticed,  unless  preceded  by 
syphilitic  or  other  lesions,  to  which  attention  has  been  directed.  There 
is  usually  a  history  of  the  gradual  appearance  of  weakness  and  ansemia, 
inability  for  mental  and  especially  for  any  physical  exertion,  headache, 
ringing  in  the  ears,  vertigo,  palpitation.  There  are,  as  the  anaemia 
gradually  develops,  alternations  of  an  improved  state  with  more  de- 
cided decline,  but  the  constant  tendency  is  downward.  These  pro- 
dromal symptoms  last  from  a  few  months  to  several  years,  the  average 

*  Wagner,  "  Manual  of  General  Pathology,"  p.  546,  American  edition. 


LEUCOCYTHEMIA.  197 

being  about  eighteen  months.  As  the  cases  progress,  the  condition  of 
anaemia  becomes  more  profound  ;  the  lymphatics  of  the  neck,  or  groin, 
or  other  superficial  parts,  are  found  to  be  somewhat  enlarged,  and  now 
careful  palpation  discloses  enlargement  of  the  spleen.  There  are,  then, 
extreme  pallor,  weakness  and  exhaustion,  and  breathlessness  on  the 
slightest  exertion.  The  headache,  vertigo,  and  tinnitus  continue,  and 
the  mental  state  is  depressed,  hypochondriacal,  and  irritable,  "  due  to 
the  accumulation  of  white  corpuscles  in  the  capillary  vessels  of  the 
brain."*  The  vision  is  obscure  and  amblyopic.  There  are  now  and 
then,  without  apparent  cause,  attacks  of  profuse  sweating,  and  scaly 
and  pustular  eruptions.  There  is  usually  some  feverishness  toward 
evening,  and  the  pulse  is  always  accelerated.  Oedema  of  the  ankles, 
puffiness  of  the  eyelids,  and  some  effusion  in  the  cavities  are  results  of 
the  hydrgemia.  The  changed  condition  of  the  blood  also  induces  the 
hemorrhagic  cachexia  or  diathesis,  and  bleeding  occurs  from  the  nose, 
mouth,  and  other  mucous  surfaces,  and  from  slight  woundSj  so  that 
the  least  abrasion  or  cut  gives  rise  to  severe  hsemorrhage.  The  ves- 
sels remain  unaffected  except  by  capillary  thromboses,  due  to  the  aggre- 
gation and  adhesion  of  white  cells,  and  such  changes  in  their  walls  as 
are  produced  by  imperfect  nutrition.  A  soft-blowing  murmur — anaemic 
murmur — is  audible  at  the  base  of  the  heart.  The  appearance  of  the 
blood  is  very  characteristic.  A  ready  method  of  demonstrating  its  char- 
acter has  been  mentioned  by  Sir  William  W.  Gull  f — that  is,  "  puncture 
the  finger  of  the  patient,  and  receive  the  blood  on  to  a  piece  of  white 
linen,  or  a  lawn  handkerchief,  and  put  by  the  side  of  it  a  similar  stain 
of  blood  from  a  healthy  subject.  The  full  color  of  the  latter  contrasts 
strikingly  with  the  stain  of  the  former,  which  is  hardly  of  a  blood-color, 
and  translucent."  The  relative  proportion  of  blood-globules  is  best 
ascertained  by  counting,  employing  for  this  purpose  the  hsemacytometer 
as  arranged  by  Gowers.J  In  order  to  constitute  leucocythemia,  it  has 
been  attempted  to  fix  arbitrary  numbers,  but,  while  the  proportion  of 
white  to  red  corpuscles  must  be  increased  very  largely  above  the  nor- 
mal, yet  no  definite  number  can  be  stated,  and  hence  the  diagnosis 
must  rest  rather  on  the  concurrence  of  the  splenic  and  lymphatic  en- 
largements with  increase  of  the  white  corpuscles.  It  may,  however, 
be  stated,  as  an  approximation  to  the  truth,  that  the  relative  proportion 
of  white  to  red  should  be  reduced  to  one  to  six,  in  order  to  constitute 
true  leucocythemia.  It  has  already  been  stated  to  what  extent  the  dis- 
proportion may  be  carried  in  this  disease  when  fully  established.  "When 
the  spleen  has  reached  its  maximum,  the  abdomen  is  greatly  enlarged, 

*  Ollivier  et  Ranvier,  "  Xouvelles  Observations  pour  servir  a  I'Histoire  de  la  Leucocy- 
themie;  "  "Archives  de  Physiologic,"  vol.  ii,  1869,  p.  518. 

■f  "Transactions  of  the  Pathological  Society,"  vol.  xxix,  18*78,  p.  383. 

jf.  The  author  uses  the  instrument  of  Dr.  W.  R.  Gowers,  as  made  by  Hawksley,  of  Lon- 
don. 


198  DISEASES   OF   THE   BLOOD-FORMING   ORGANS. 

and  prominent,  but  in  oi'dinary  cases  an  increase  of  size,  and  usually 
of  density,  can  be  ascertained  on  palpation.  The  mesenteric  glands 
can  usually  be  felt  through  the  abdominal  walls,  enlarged  and  firmer. 
The  inguinal,  cervical,  and  other  lymphatic  glands,  are  also  enlarged. 
A  capital  illustration  of  these  is  given  in  the  plate  accompanying  Sur- 
geon-Major Porter's  case,  *  as  reported  to  the  London  Pathological 
Society. 

The  tumors  of  the  tongue  and  tonsils  interfere  with  mastication 
and  the  act  of  swallowing  ;  the  gums  become  sjDongy  and  tender.  The 
appetite  may  be  keen  ;  it  may  be  normal ;  it  maybe  wanting  entirely. 
Constipation  at  first  is  present ;  then  diarrhoea  alternates  with  consti- 
pation, and  finally  diarrhoea  persists.  The  urine  has  a  higher  specific 
gravity  than  normal — from  1020  to  1030.  The  urea  is  greatly  dimin- 
ished, but  the  uric  acid  is  increased,  and  hypoxanthin  is  present,  in  the 
cases  of  splenic  leucocythemia. 

Course,  Duration,  and  Termination. — Leucocythemia  is  essentially 
a  chronic  malady.  Its  origin  can  not  be  often  determined,  because  there 
is  a  slow  development  of  uneasiness  in  the  splenic  region,  fullness  of 
the  abdomen,  breathlessness  on  exertion,  and  anaemia  and  pallor  of  the 
skin.  The  swelling  of  the  spleen,  until  its  size  is  considerable,  escapes 
recognition  ;  when,  however,  the  external  lymphatic  glands  enlarge, 
attention  is  earlier  directed  to  the  nature  of  the  case.  Then  an  ex- 
amination of  the  blood  furnishes  conclusive  evidence.  When  the 
hsemorrhagic  diathesis  comes  on,  bleeding  may  be  so  severe  as  to  ex- 
haust the  patient  rapidly,  or  death  may  occur  suddenly  by  cerebral 
haemorrhage.  The  course  and  duration  of  cases  are  materially  affected 
by  the  hemorrhagic  diathesis.  When  this  does  not  exist,  the  progress 
is  much  slower  and  the  duration  more  prolonged.  The  glandular  and 
splenic  enlargements  may  become  enormous,  and  the  patient  die  ulti- 
mately of  exhaustion,  death  being  preceded  by  cerebral  symptoms — 
delirium,  stupor,  and  insensibility.  The  case  may  be  terminated  by 
some  intercurrent  malady,  as  pericarditis,  pleuritis,  pneumonia,  etc.  The 
symptoms  of  the  first  stage,  as  already  stated,  continue  for  months, 
even  years,  the  average  being  about  eighteen  months,  and  the  second 
stage,  or  fully  developed  malady,  lasting  about  one  year.  Probably 
the  average  duration  of  the  whole  disease  is  two  years. 

Diagnosis. — In  the  first  stage  of  this  malady  a  distinction  is  not 
possible  from  ordinary  ancemia  and  chlorosis.  When,  however,  the 
spleen  enlarges,  and  the  lymphatic  glands  also,  and  the  anasmia  be- 
comes extreme,  the  picture  of  the  disease  is  complete,  and  no  one  pos- 
sessed of  any  knowledge  could  fail  to  recognize  it.  In  the  early  stage, 
the  persistence  of  the  ansemia  under  appropriate  treatment,  the  ex- 
treme degree  of  pallor,  the  breathlessness  under  slight  exertion,  the 

*  "Transactions  of  the  Pathological  Society,"  vol.  xxix,  p.  339,  op.  cit. 


LEUCOCYTHEMIA.  199 

vertiginous  sensations,  the  lioemorrhagic  diathesis,  must  awaken  sus- 
picion as  to  the  character  of  the  malady,  before  the  splenic  disease 
manifests  itself. 

Treatment. — Unfortunately,  we  possess  no  specific  against  this  dis- 
ease, and  hence  the  treatment  must  be  symptomatic.  Iron,  which  is  a 
specific  in  anaemia,  has  no  influence  of  a  curative  kind  in  leucocythe- 
mia,  but  it  is  useful  as  supplying  a  material  needed  in  the  process  of 
repair.  There  are  several  remedies  which  affect  the  spleen,  in  a  way 
which  indicates  a  specificity  of  action  :  they  are  quinia,  ergotin,  and 
electricity.  Quinia,  iron,  and  ergotin  can  be  given  together  in  pill-form 
— five  grains  of  quinia,  one  grain  of  reduced  iron,  and  two  grains  of 
ergotin,  should  be  administered  three  times  a  day.  Simultaneously, 
electi'icity  can  be  applied  in  the  form  of  f aradic  electricity  to  the  sple-  * 
nic  region,  or  by  means  of  an  insulated  electrode  in  the  rectum,  and 
the  other  over  the  spleen,  A  slowly  interrupted  galvanic  current  is, 
the  author  believes,  more  efficient.  Good  results  are  obtained  from 
the  local  application  of  the  ointment  of  the  biniodide  of  mercury — un- 
guentum  hydrargyri  iodidi  rubri — to  the  splenic  region.  The  oint- 
ment should  be  thoroughly  rubbed  in  while  the  direct  rays  of  the  sun 
are  falling  on  the  part,  or  before  a  bright  fire.  The  ointment  is  rubbed 
in  daily,  until  the  skin  begins  to  vesicate,  when  it  must  be  discontinued, 
but  resumed  again  when  the  skin  has  recovered  from  the  effects  of 
previous  applications.  As  the  breathlessness  on  exertion,  the  vertigo, 
the  mental  troubles,  the  effusions,  the  haemorrhages,  etc.,  are  due  to  the 
impoverished  blood,  attention  must  be  directed  to  the  central  lesion, 
rather  than  administer  remedies  for  individual  symptoms.  In  some 
cases  good  results  have  apparently  followed  tranfusion  of  blood  ;  but 
they  were  examples  of  the  hajmorrhagic  diathesis,  rather  than  of  true 
lencocythemia.  In  the  latter  disease  transfusion  is  useless — three  cases 
in  which  it  was  employed  by  Stoll,  of  Wurzburg,  having  proved  fatal. 
As  the  function  of  blood-production  is  at  fault,  attention  to  the  first 
steps  in  the  process  is  necessary  :  in  other  words,  careful  alimentation 
is  of  great  importance.  Whether  the  appetite  be  languid  or  voracious, 
to  insure  thorough  digestion,  pepsin  and  muriatic  acid  should  be  ad- 
ministered after  each  meal.'  As,  in  the  progress  of  the  disease,  the 
liver  and  intestinal  glandular  apparatus  are  disabled,  fats,  starches,  and 
sugars  should  be  excluded  from  the  diet  as  far  as  possible,  and  the 
patient  be  fed  on  fresh  meats,  milk,  eggs,  and  fish.  Cases  not  yielding 
to  the  plan  above  indicated  may  be  treated  with  arsenic,  arseniate  of 
iron,  especially  Fowler's  solution,  and  the  phosphates  or  compound 
sirup  of  the  hypophosphites.  These  remedies  should,  of  course,  be 
pushed,  especially  the  phosphates,  for  no  immediate  results  can  be  ob- 
tained from  them.  Arsenic  has  been  administered  hypodermatically, 
and  injected  directly  into  the  substance  of  the  enlarged  spleen  with 
asserted  advantao^e. 


200  DISEASES   OF   THE   BLOOD-FORMING   ORGANS. 


MELAN^SMIA. 

Pathogeny. — The  term  raelanoemia  is  ai^plied  to  a  condition  of  the 
blood  in  which  are  found  small  brownish  or  black  masses,  scarcely  so 
large  as  a  red-blood  globule,  of  pigment  matter.  Sometimes  these  par- 
ticles are  oval,  or  round  in  shaj)e,  sometimes  irregular,  and  rarely 
stratified  by  the  presence  of  a  colorless  capsule  (Rindfleisch).  Occa- 
sionally true  j)igment-cells  are  observed.  This  pigment  is  found  every- 
where in  the  blood,  but  exists  in  greatest  quantity  in  the  spleen,  which 
becomes,  according  to  the  quantity,  a  chocolate,  brownish,  or  blackish 
color.  The  spleen  may,  indeed,  be  almost  the  sole  place  of  deposit, 
^but  the  liver  is  next  in  respect  to  place  and  quantity,  and  after  the 
liver  ai-e  the  lungs,  brain,  and  kidneys.  Opinions  differ  as  to  the  origin 
of  the  pigment,  but  the  weight  of  authority  is  in  favor  of  the  splenic 
origin,  and  that  it  is  a  product  of  the  disintegration  of  the  red-blood 
corpuscles.  As  during  malarial  fever  this  destruction  of  the  red  cor- 
puscles is  more  rapid  than  in  any  other  form  of  acute  infectious  dis- 
ease, melantemia  is  a  product  of  malarial  diseases.  The  pathological 
changes  characteristic  of  this  state  are  found  in  the  spleen,  liver,  lym- 
phatic glands,  marrow  of  bones,  etc.  The  spleen  is  enlarged,  its  con- 
sistence soft,  if  there  have  been  recent  attacks,  and  firmer  if  consider- 
able time  has  elapsed.  The  color  depends  on  the  quantity  of  pigment, 
and  is  dark  slate,  or  brown,  or  black.  The  deposits  of  pigment  take 
place  chiefl}^  along  the  veins,  which  are  bordered  by  a  dark  line,  and 
to  a  less  extent  along  the  arteries,  and  the  whole  splenic  pulp  may  be 
tinted  by  it.  The  lymphatics  and  the  marrow,  also,  contain  pigment, 
which,  with  lymphoid  cells,  is  found  in  the  vicinity  of  the  vessels. 
Characteristic  changes,  due  to  pigment  deposition,  also  occur  in  the 
liver.  As  elsewhere,  the  pigment  deposits  are  found  alongside  the 
vessels.  According  to  Rindfleisch,*  small  extravasations  of  blood  in 
Glisson's  capsule,  and  in  the  parenchyma  of  the  liver,  initiate  the  pig- 
ment formation.  The  pigment  granules  accumulate  about  the  branches 
of  the  portal  vein  and  hepatic  artery,  about  the  intralobular  and  he- 
patic veins,  but  the  hepatic  cells  are  not  involved.  The  whole  organ 
has  a  steel-gray  or  blackish  tint.  Ultimately  the  nutrition  of  the 
organ  may  be  so  impaired  that  atrophy  results. 

As  the  pigment  granules  may  be  larger  in  caliber  than  the  blood 
corpuscles,  they  will  necessarily  be  arrested  in  those  organs  having  a 
fine  capillary  network.  Pigment  embolisms  of  the  cerebral  vessels 
are,  consequently,  results  of  this  process.  Pigment  blocking  of  the 
cerebral  capillaries  has  precisely  the  same  effects  that  other  emboli 
produce  :  collateral  hypersemia,  extravasations,  and  oedema,  with  the 
important  structural  alterations  following  in  their  wake. 

*  "Pathological  Histology,"  American  edition,  p.  18*7. 


MELAN^MIA. 


201 


Symptoms. — Melantemia  is  an  accident  or  complication  of  the  se- 
verer cases  of  malarial  fever.     The  changes  in  the  spleen  and  liver  do 
not  cause  symptoms,  except  the  enlai-gement  of  the  former  organ,  to 
be  made  out  by  palpation  and  percussion.     The  cerebral  symptoms 
are,  however,  very  pronounced.     There  are  present,  when  the  pigment 
embolisms  occur,  more  or  less  intense  headache,  vertigo,  delirium  either 
low-muttering,  or  active  and  furious,  passing  into  stupor,  coma,  and 
insensibility.      There  are  occasionally  paralysis  and  epileptiform  at- 
tacks, but  usually  the  motor  disturbances  are  not  more  than  twitchino-s 
of  the  muscles,  ptosis  and  weakness  of  the  muscles  of  the  extremities. 
In  cases  seen  by  the  author  the  delirium  was  wild — delirium  ferox — 
and  the  motor  troubles  were  those  of  paresis  of  muscular  groups.     In 
the  author's  cases  also  there  was  a  very  high  temperature,  to  which  the 
cerebral  disturbance  may  have  been  in  part  due.     In  the  more  chronic 
cases,  without  fever,  there  are  persistent  headache  and  vertigo,  the 
strength  is  easily  exhausted,  the  nutrition  inactive,  and  the  surface, 
especially  of  those  parts  of  the  body  exposed  to  the  light,  has  a  bronzed 
appearance.     In  such,  we  may  assume  that  the  pigmentation  of  the 
brain  is  confined  to  deposits  alongside  the  vessels,  and  does  not  in- 
clude embolic  obstruction  of  the  capillaries  by  pigment  masses.    When 
the  last-mentioned  condition  exists,  there  will  be  more  decided  mental 
symptoms,  epileptiform  attacks,  paralysis,  etc.     In  the  milder  form, 
recovery  may  ultimately  ensue  if  the  patient  be  removed  from  mias- 
matic influences.     In  those  cases  of  capillary  embolisms,  it  is  doubt- 
ful if  recovery  ever  can  take  place.     Nevertheless,  treatment  must  be 
pursued  from  the  symptomatic  standpoint,  for  it  may  be  that  success 
will  eventually  be  the  reward  of  persistent  efforts. 

Treatment. — There  are  two  therapeutical  indications  :  to  check  the 
waste  of  red-blood  globules  ;  to  effect  the  solution  and  extrusion  of 
pigment.  Quinine,  iron,  ergotin,  and  digitalis — which  may  be  com- 
bined— are  the  most  efficient  remedies  for  the  first  indication ;  pyro- 
phosphate of  sodium  for  the  second.  If  the  symptoms  are  acute, 
quinia  must  be  given  in  large  doses — twenty  to  forty  grains  a  day — if 
less  so,  five,  even  three  grains  three  times  a  day.  The  other  remedies 
should  be  prescribed  accordingly.*  The  utility  of  the  phosphate  of 
sodium  consists  in  its  power  to  maintain  the  alkalinity  of  the  blood,  in 
its  effects  on  the  hepatic  secretion,  and  in  its  influence  over  the  meta- 
morphosis of  tissue. 

HEMOPHILIA. 

Definition. — The  term  haemophilia  is  applied  to  a  congenital  state 
characterized  by  the  habitual  occurrence   of  haemorrhages.     As  the 

*  5.  Quinise  sulph.  3  j,  ferri  redacti  gr.  x,  ergotin  3j,  digitalis  gr.  x.  Make  into 
ten  wafers.  One  wafer  three  times  a  day.  5  •  Sodii  pyropiiosphat.  §  j,  ferri  pyrophos- 
phat.  3j.     M.     Take  a  teaspoonful  in  sufficient  water  three  times  a  day  before  meals. 


202  DISEASES   OF  THE   BLOOD-FORMING   ORGANS. 

disposition  to  bleeding  is  inherited,  and  is  transmitted  in  families, 
persons  so  affected  are  called  "  bleeders." 

Causes. — Heredity  is  the  most  important  factor  in  its  causation. 
It  is  an  unfortunate  fact  that  families  of  bleeders  are  remarkable  for 
fertility.  The  males  are  affected  thirteen  times  more  frequently  than 
females  (Immermann  *),  but,  on  the  other  hand,  women  transmit  the 
disease  more  certainly  than  males — for  example,  a  male  bleeder  mar- 
rying a  healthy  woman,  without  taint  of  haemophilia,  has  children 
usually  free  from  this  hereditary  disposition  ;  but  a  female  bleeder 
marrying  a  healthy  male  has  quite  uniformly  bleeder  children.  Again, 
if  a  woman,  member  of  a  bleeder  family,  but  herself  not  a  bleeder, 
marry,  she  will  have  some  children  who  inherit  the  family  taint.  The 
disposition  to  bleeding  usually  manifests  itself  about  the  first  denti- 
tion, and  in  a  large  proportion  within  the  first  year.  The  haemor- 
rhagic  diathesis  existing,  a  slight  injury  will  suffice  to  start  the  bleed- 
ing :  thus,  lancing  the  gums,  leech-bites,  the  Jewish  rite  of  circum- 
cision, slight  cuts  or  abrasion  of  the  skin,  have  been  followed  by  un- 
controllable haemorrhage.  The  bleeding  having  once  occurred,  the 
tendency  to  attacks  is  thereby  greatly  increased. 

Symptoms. — There  does  not  seem  to  be  anything  peculiar  in  the 
bleeders  as  respects  bodily  conformation,  temperament,  habits,  and 
disposition,  except  the  htemorrhagic  diathesis,  although  it  is  said 
that  they  are  usually  persons  of  superior  mental  endowments 
(Leggf). 

There  are  two  distinct  forms  of  haemorrhage  :  the  external,  in  which 
the  blood  pours  out  on  the  surface  of  the  wound  or  abrasion  ;  the  ijiter- 
stitial,  in  which  the  blood  diffuses  into  the  interstices  of  the  adjacent 
tissues.  Frequently,  if  not  usually,  both  forms  occur  at  the  same  time. 
The  external  form  may  be  the  result  of  injury,  and  is  therefore  tr^aii- 
matic,  or  it  occurs  spontaneously,  and  is  named  accordingly.  The  ex- 
ternal and  traumatic  form  is  single,  for  it  is  comparatively  rare  for 
more  than  one  point  of  injury  to  exist  at  a  time.  On  the  other  hand, 
the  spontaneous  haemorrhage,  indicating  a  more  active  state  of  the  vice, 
may  occur  simultaneously  at  several  points.  The  most  usual  site  of 
the  spontaneous  haemorrhage  is  the  mucous  membrane,  especially  of 
the  oral  and  nasal  cavity  ;  of  the  stomach  and  intestines  ;  of  the  bron- 
chi ;  of  the  genito-urinary  passages — named  in  the  relative  order  of  fre- 
quency. Recent  cicatrices,  that  are  still  vascular,  ulcers  of  the  skin,  and 
irritated  surfaces,  invite  the  haemorrhage.  Again,  in  the  most  perfect 
specimens  of  haemophilia,  bleeding  occurs  without  any  change  in  the 
skin  to  start  it,  and  takes  place  from  the  fingers,  toes,  lobes  of  the  ears, 
back  of  the  hand,  etc.     By  far  the  most  common  form  of  bleeding  is 

*  Ziemssen's  "  Cyclopaedia,"  vol.  xvii,  article  "  Haemophilia." 

f  Dr.  J.  Wickhara  Legg,  "  Treatise  on  Haeinophilia,"   London,  1872,  H.   K.   Lewis, 
p.  158. 


I 


HiEMOPHILIA.  203 

epistaxis,  which  occurs,  according  to  the  statistics  of  Grandidier,*  four 
times  more  often  than  hemorrhage  from  the  gums,  which  comes  next 
in  frequency,  then  intestinal  haemorrhage,  haemoptysis,  hsematuria, 
haematemesis,  etc.,  as  named. 

The  blood  escapes  from  the  smallest  capillaries,  under  very  strong 
pressure,  and  persists  obstinately,  in  spite  of  the  most  powerful  means 
to  arrest  it,  hours,  days,  and  weeks  together.  The  result  is  an  extreme 
degree  of  anaemia — the  skin  pallid,  the  face  drawn,  lips  retracted,  the 
mucous  membrane  white  and  sticky,  the  pulse  small,  weak,  or  not  to 
be  felt  at  the  wrist ;  a  soft,  systolic  murmur  at  the  base,  and  a  venous 
hum  over  the  great  veins  ;  or  the  action  of  the  heart  may  be  too  feeble 
to  be  recognized.  Consciousness  may  be  lost,  and  death  occur  in  syn- 
cope. Owing  to  the  extreme  cerebral  anaemia,  there  may  be  illusions, 
hallucinations,  or  attacks  of  convulsions,  as  in  animals  bled  to  death 
(Kussmaul  and  Tenner f).  In  the  syncope,  a  hemorrhage  which  could 
not  be  arrested  may  cease  spontaneously.  Notwithstanding  the  enor- 
mous losses  of  blood,  its  reproduction  takes  place  quickly,  and  between 
the  seizures  the  bleeders  may  present  the  rosy  hue  of  health.  The 
amount  sometimes  lost  seems  almost  incredible — in  one  case  (Coates) 
reaching  the  enormous  loss  of  three  gallons  in  eleven  days.  The  state 
of  the  blood  in  bleeders  varies  with  the  conditions  of  health  and  after 
loss  by  hcemorrhage — that  is,  becomes  more  watery  with  loss — but  other- 
wise there  is  no  difference  in  composition  as  compared  with  healthy 
blood,  except  that  the  former  contains  somewhat  more  red  globules 
and  more  fibrin  than  the  latter,  or  is  richer  than  ordinary  normal 
blood.  The  interstitial  bleedings  occur  chiefly  in  the  skin  and  subcu- 
taneous connective  tissue,  and  when  traumatic  are  observed  in  parts 
subject  to  injury,  as  the  back,  buttocks,  trochanters,  while  the  spon- 
taneous are  observed  mostly  on  the  soalp,  the  scrotum,  and  the  legs. 
Very  small  extravasations  are  called  petechioe  ;  larger  ones,  ecchynioses. 
The  blood  undergoes  the  usual  changes  of  extravasated  blood  :  at  first 
a  bluish  red,  then  brownish,  with  green  borders,  then  yellowish — sev- 
eral weeks  being  occupied  in  these  transformations.  Sometimes  con- 
siderable accumulations  of  blood  are  formed,  constituting  blood-tumors, 
and  are  found  about  the  false  ribs,  on  the  back,  on  the  inner  face  of  the 
thighs,  in  the  popliteal  space,  and  on  the  lower  extremities.  They  vary 
in  size  from  a  hickory-nut  to  a  goose-egg,  and  attain  even  larger  pro- 
portions, and  also  vary  in  firmness  according  to  their  position.  They 
are  of  a  bluish-black  color,  and  are  surrounded  by  a  rose-colored  zone, 
tender  to  the  touch,  and  signifying  the  formation  of  a  limiting  mem- 
brane. These  tumors  may  undergo  the  usual  preparatory  changes  and 
be  slowly  absorbed,  or  suppuration  may  occur,  and  discharge  of  pus  and 

*  Schmidt's  "  Jahrbiicher,"  vol.  cxvii,  p.  329,  "  Bericht  iiber  die  neucrn  Beobachtun- 
gen  und  Leistungen  ein  Gebiete  der  Haemophilie  seit,"  1854. 
t  Sydenham  Society  edition. 


204  DISEASES   OF   THE   BLOOD-FORMING   ORGANS. 

shreds  of  tissue  take  place,  with  considerable  haemorrhage.  The  only 
changes  to  account  for  the  phenomena  of  hsemoi^hilia  are  abnormal 
disposition  and  arrangement  of  the  superficial  vessels  of  the  body. 
The  superficial  vessels  are  abnormally  large,  the  intima  remarkably 
thin.  On  the  other  hand,  the  lumen  of  the  large  arteries  (aorta  and 
pulmonary)  is  found  to  be  narrow.  The  intima  of  both  classes  of 
vessels  is  usually  in  a  state  of  fatty  degeneration.  There  has  usually 
existed  an  hypertrophy  of  the  left  ventricle.  These  changes  in  the 
vascular  system,  and  the  condition  of  vascular  fullness  and  congestion, 
which  marks  the  healthy  state  of  bleeders,  together  with  the  abnormal 
richness  of  the  blood,  serve  in  a  measure  to  account  for  the  extraordi- 
nary clinical  history  of  this  disease. 

Complications. — In  the  bleeder  families  neuralgic  and  rheumatic 
affections  seem  common.  Toothache  and  myalgia  are  said  to  be  fre- 
quent.    Rheumatic  joint  and  muscular  affections  also  occur. 

Duration  and  Termination. — The  duration  of  hgemophilia  is  the  life 
of  the  individual.  If  the  bleeder  escape  the  accidents  of  childhood, 
there  may  be  no  manifestation  of  the  diathesis  until  after  adult  life.  A 
young  woman  died  on  her  marriage-night,  from  haemorrhage  occasioned 
by  rupture  of  the  hymen.  A  single  haemorrhage  may  take  life  in  a  few 
hours,  as  in  the  case  just  narrated,  or  death  may  result  from  several 
weeks  of  bleeding.  The  usual  result  is  death.  Such  small  operations 
as  extraction  of  teeth,  circumcision,  leeching,  etc.,  are  very  apt  to  cause 
death,  while  vaccination  is  much  less  dangerous.  Of  152  bleeder  boys, 
133  died  before  attaining  twenty-one  years  of  age.*  The  haemorrhagic 
disposition  may  disappear  in  middle  life,  but  this  has  happened  in  nine 
cases  only  ;  and,  when  it  does  cease,  rheumatic  and  gouty  attacks  are 
experienced. 

Treatment. — All  injuries  must  be  carefully  guarded  against.  Bleed- 
ing from  any  abrasion  or  puncture  should  be  restrained  by  pressure,  if 
possible.  Every  form  of  astringent  vegetable  and  mineral  has  been 
used.  Epistaxis,  which  is  the  most  usual  form  of  hemorrhage,  is  best 
arrested  by  plugging  the  nares  and  the  application  of  ice,  and  by  the 
administration  of  ergotin.  Bleeding  from  the  gums  is  more  easily 
handled,  in  that  the  styptic  preparations  of  iron,  the  actual  cautery, 
and  compression  can  be  used.  In  haematuria,  krameria,  infusion  of 
digitalis,  ergotin,  and  gallic  acid  should  be  administered.  Of  the  sys- 
temic remedies  there  can  be  no  question  as  to  the  superiority  of  ergot 
and  digitalis,  and  experience  is  in  harmony  with  physiological  ex- 
periment. Cures  have  apparently  followed  the  use  of  ergot.  The 
administration  should  never  be  subcutaneously,  and  the  dose  of  the 
aqueous  extract  will  range  from  two  to  five  grains,  as  often  as  may 
be  necessary.     When  attacks  are  impending,  a  brisk  cathartic  of  Ep- 

*  Grandidier,  op.  cit.,  p.  333. 


SCORBUTUS.  205 

som  salts  should  be  administered  to  lower  the  blood-pressure,  and 
the  diet  should  consist  of  fruits  and  vegetables  only.  Sulphuric  acid 
in  dilute  solution  should  be  taken  as  a  drink.  Full  doses  of  digi- 
talis, the  patient  maintaining  absolute  recumbency,  should  then  be 
administered,  and  when  the  haemorrhage  comes  on  the  exhibition  of 
ergotin,  etc.,  should  be  practiced.  This  method  is  the  best  now  known 
for  arresting  the  attacks  of  bleeding. 

SCORBUTUS— SCURVY. 

Definition. — Scurvy  is  a  disease  of  nutrition,  in  which  the  blood  is 
so  far  impoverished  that  transudations  occur,  and  large  hsemorrhagic 
ecchymoses  become  visible  in  various  places. 

Causes. — This  disease  occurs  more  frequently  in  men,  because  their 
occupations  expose  them  more  to  its  causes,  and  in  the  feeble  and 
cachectic,  especially  those  who  are  debilitated  by  syphilis  and  mercu- 
rialism,  and  by  marsh-miasm.  Scurvy  usually  occurs  in  bodies  of 
men,  as  soldiers  and  sailors,  who  are  under  the  same  evil  influences, 
and  hence  numbers  are  attacked  nearly  simultaneously — the  cachectic 
falling  victims  before  the  robust.  The  chief  factor  is  defective  ali- 
mentation, not  in  respect  to  quantity  so  much  as  quality.  The  contin- 
ued use  of  salted  meat  and  fish  and  the  absence  of  fresh  meat  and  fresh 
vegetables  for  a  long  period  from  the  diet  are  the  great  cause,  and  all 
other  influences  are  merely  adjuncts.  When  such  fresh  vegetables  as  jjo- 
tatoes,  cabbage,  and  onions,  are  supplied,  although  the  other  components 
of  the  ration  may  consist  of  salted  and  dried  meats,  scurvy  will  not  oc- 
cur. So  well  is  this  fact  understood  now,  that  some  one  of  these  arti- 
cles always  enters  into  the  diet  of  armies  and  prisons,  and,  if  not  attain- 
able in  a  perfectly  fresh  state,  are  supplied  in  the  form  of  "  desiccated 
vegetables,"  sauerkraut,  etc.  Garrod,  and  afterward  Hammond,  at- 
tempted to  show  that  the  constituent,  the  absence  of  which  is  the  cause 
of  scurvy,  is  potash  ;  and  that  those  vegetables  most  effective  in  pre- 
venting and  curing  scurvy  are  remarkable  for  the  quantity  of  potash 
which  they  contain,  and  of  these  the  potato  stands  at  the  head.  Un- 
doubtedly, bad  hygienic  influences  exert  an  influence  in  the  produc- 
tion of  scurvy.  Living  in  houses  that  are  dark,  damp,  and  confined, 
want  of  exercise,  depression  of  spirits  (defeat),  ennui,  all  have  more 
or  less  effect  in  depressing  the  bodily  functions,  and  thus  favor  the  ill 
effects  of  an  improper  diet. 

Pathological  Anatomy.— Cadaveric  rigidity  is  slight ;  suggillations 
are  extensive  on  the  dependent  parts  ;  petechise  and  ecchymoses  are 
found  on  the  body  and  the  extremities  ;  the  skin  is  muddy,  inelastic, 
and  scaly.  The  petechial  spots  are  formed  by  an  extravasation  pro- 
ceeding from  the  capillary  network  about  the  hair-follicles,  while  the 
larger  ecchymoses  come  from  the  vessels  of  the  derma.     The  indura- 


206  DISEASES   OF   THE   BLOOD-FORMING   ORGANS. 

tions  of  the  connective  tissue,  subcutaneous  and  deeper,  are  due  to 
infiltration  by  coagulated  blood.  The  subsequent  changes  in  the 
clots  are  the  explanation  of  the  appearance  presented  by  these  indura- 
tions, and  depend  on  the  greater  or  less  amount  of  red  globules,  and 
on  the  solution  of  the  fibrin,  or  its  organization.  The  fibrin  may  be- 
come organized  to  that  extent  in  which  muscular  atrophy  and  con- 
tractions resulting  in  deformities  must  ensue.  In  a  similar  manner, 
an  extravasation  into  the  substance  of  a  muscle  may  lead  to  atrophy, 
the  muscular  elements  being  supplanted  by  indurated  connective  tis- 
sue. These  atrophic  alterations  and  deformities  are  results  of  long- 
standing changes.  Recent  extravasations,  in  scorbutus,  under  appro- 
priate management,  undergo  the  same  regressive  changes  as  a  blood- 
clot  in  the  normal  state,  though  somewhat  slower,  and  nothing  is 
found  post  mortem  after  the  process  is  completed.  The  mucous  mem- 
brane of  the  mouth  is  the  seat  of  extensive  h£emorrhagic  infiltration, 
and  is  therefore  swollen  and  spongy  ;  but  in  old  cases  the  gums  may  be 
thickened  and  indurated,  due  to  the  formation  of  new  connective  tis- 
sue. There  is  more  or  less  eifusion  into  the  serous  cavities  of  a  straw- 
colored  or  sanguinolent  serum  ;  the  membranes  are  injected,  or  coated 
with  exudations,  or  stained  by  spots  of  hremorrhagic  extravasation. 
The  heart  is  flabby,  soft,  pale,  and  haemorrhages  are  found  in  its  mus- 
cular substance.  The  lungs  are  somewhat  oedematous,  the  posterior 
and  dependent  parts  the  seat  of  hypostatic  alterations,  and  catarrhal 
and  croupous  inflammation  products  are  found  at  the  base  and  else- 
where. There  may  be  extensive  solidification  from  croupous  pneumo- 
nia, or  hsemorrhagic  infarctions.  There  are  numerous  ecchymoses  in 
the  bronchi.  The  peritoneum  is  altered  in  the  same  manner  as  the 
pleura — the  evidences  of  inflammation  existing  on  the  visceral  and 
parietal  layers  in  the  form  of  exudations  and  extravasations.  The 
intestinal  mucous  membrane  is  altered  by  hsemorrhagic  spots  and  ero- 
sions, and  sometimes  by  extensive  losses  of  substance.  The  liver  is 
not  usually  affected.  The  spleen,  although  often  unchanged,  is  some- 
times enlarged  and  softer  than  normal,  and  occasionally  there  are 
found  hsemorrhagic  infarctions.  The  kidneys  may  be  healthy,  but 
the  mucous  membrane  of  the  pelves,  ureters,  and  bladder  contains  ero- 
sions and  ecchymoses.  Important  alterations  occur  in  the  blood — the 
number  of  red  globules  diminished  ;  the  white  relatively  increased ; 
the  iron,  potassa,  and  albumen  lessened. 

Symptoms. — The  onset  of  scurvy  is  so  gradual  that  the  patients  do 
not  know  when  it  began.  They  become  a  little  paler,  and  fatigue 
more  readily,  but  after  a  time  there  is  an  appearance  of  ansemia,  and 
such  a  degree  of  weakness  that  the  least  effort  gives  rise  to  exhaustion, 
and  to  a  sense  of  prsecordial  oppression  and  weakness  and  palpitation 
of  the  heart.  The  increasing  weakness  is  accompanied  by  a  sense  of 
soreness  and  fatigue  in  the  muscles,  like  that  induced  by  prolonged 


SCORBUTUS. 


207 


hard  work,  but  rest  in  bed  relieves,  as  exercise  increases,  these  sensa- 
tions. These  muscular  pains  are  especially  felt  in  the  back  and  the 
calves  of  the  legs,  and  have  a  rheumatic  character,  and  are  often  sup- 
posed to  be  rheumatic.  The  scorbutic  subjects  become  exceedins^ly 
sensitive  to  cold,  and  continually  seek  the  fire  or  put  on  additional 
clothing.  They  are  somnolent,  apathetic,  and  indisposed  to  any  effort, 
mental  or  physical ;  are  dejected  in  mind,  and  wear  an  expression  of 
sadness.  The  facies  presents  an  unearthly  aspect ;  the  eyes  are  sunken 
and  surrounded  by  livid  aureola  ;  the  lips  are  thin,  retracted,  cya- 
nosed  ;  the  skin  sallow,  pallid,  dry,  scaly,  and  earthy,  and  here  and 
there  may  be  found  indistinct  spots  of  bronze  discoloration.  The  sub- 
cutaneous fat  has  diminished,  the  muscles  are  soft  and  small,  and  the 
body-weight  is  reduced.  Such  are  the  symptoms  of  the  initial  or 
prodromal  stage.  They  indicate  ansemia,  and  are  suggestive  of  scor- 
butus only  because  of  the  surroundings,  and  the  presence  of  other 
cases.  The  duration  of  this  period  is  from  a  week  to  two  or  three 
months.  This  prodromal  stage  may  be  wanting,  but  in  the  cases  ob- 
served by  the  author  *  was  always  present. 

The  scorbutic  stage  first  manifests  itself  in  the  gums,  which  become 
of  a  dark-bluish  color  on  their  margins,  especially  at  the  incisor  teeth, 
and  are  swollen,  projecting  between  the  teeth,  and  bleeding  with  a 
touch.  The  gums  are  also  quite  painful,  so  that  mastication  and  the 
mere  contact  of  sapid  substances  are  distressing  ;  but  those  portions 
of  the  gums  without  teeth  are  free  from  these  troubles,  and  hence  the 
toothless,  at  the  extremes  of  life,  are  exempt  from  scorbutus  of  the 
mouth.  Again,  it  sometimes  happens  that  these  changes  in  the  gums 
are  entirely  absent,  and  the  first  manifestation  of  trouble  consists  in 
suggillations  and  subcutaneous  extravasations  of  blood  and  intestinal 
haemorrhage.  On  the  other  hand,  there  are  many  instances  in  every 
collection  of  cases,  in  which  the  only  manifestation  has  been  in  the 
mouth,  coupled  with  anemia  and  muscular  feebleness.  In  the  severer 
cases  after  the  prodromal  stage,  the  weakness  increases  to  such  an 
extent  that  they  become  unable  to  retain  the  upright  posture,  and  will 
fall  into  syncope  in  the  attempt  to  assume  this  position.  The  action 
of  the  heart  becomes  very  feeble,  and  any  exertion  brings  on  severe 
palpitation,  with  a  sense  of  extreme  prascordial  oppression.  Fever 
now  comes  on,  in  many  cases  not  as  a  necessary  element  in  the  disease, 
but  a  symptomatic  expression  of  a  local  inflammation  of  a  serous  mem- 
brane or  other  inflammatory  trouble.  The  characteristic  hrvAt  of  anse- 
raia  is  audible  at  the  base  of  the  heart  and  along  the  great  vessels. 

In  the  further  progress  of  the  case  the  gums  become  much  swollen, 

*  The  author  saw  some  cases  of  scurvy  when  serving  in  the  regular  armv  as  medical 
ofiBcer  in  1857,  during  the  winter  spent  in  Utah,  the  command  being  on  half  rations,  with- 
out any  fresh  vegetables.  The  description  above  is,  in  the  main,  based  on  these  observa- 
tions. 


208  DISEASES   OF   THE   BLOOD-FORMING   ORGANS. 

rise  up  to  a  level  with  the  teeth,  are  horribly  painful,  and  undergo 
ultimately  an  "  ichorous  disintegration,"  or  diphtheritic  sloughs  form  ; 
in  either  case,  fetid,  decomposing  sloughs  are  cast  off,  leaving  the 
teeth  bare  or  loose.  Serious  deformities  are  necessarily  produced  by 
these  losses  of  substance  when  cicatrization  occurs.  Extensive  hoemor- 
rhagic  extravasations  take  place  in  the  skin,  chiefly  of  the  lower 
extremities  and  body,  but  rarely  on  the  head  or  face.  There  may 
be  purpuric  petechias,  the  size  of  a  hemp-seed,  or  vesicular  or  papu- 
lar efflorescences,  or  large  hsemorrhagic  spots  of  irregular  size,  or 
vesicles  of  large  size  filled  with  a  bloody  serum.  The  least  injury  or 
contusion  is  followed  by  a  suggillation.  The  skin,  too,  may  become 
the  seat  of  extensive  ulcerations,  gangrenous  sloughs  and  haemorrhage. 
The  subcutaneous  tissue  may  either  suddenly  or  gradually  become 
affected  by  indurations  often  of  great  extent.  They  are  at  first  red, 
and  tender,  but  presently  become  brownish,  and  the  epidermis  peels 
off,  leaving  a  discoloration  ;  or,  in  severer  cases,  an  acute  inflammation 
is  set  up,  the  skin  gives  way,  and  a  great  quantity  of  blood  with 
shreds  of  tissue,  often  gangreneous,  is  discharged,  leaving  a  more  or 
less  extensive  foul  ulcer.  The  muscles  undergo  similar  changes — 
are  occupied  by  indurations,  the  result  of  extravasation  of  blood  into 
their  substance,  and  either  acutely  inflame,  there  being  great  local 
tenderness  and  heat,  and  symptomatic  fever,  or  the  process  goes  on 
more  slowly  without  fever.  Haemorrhages  take  place  from  various 
mucous  surfaces  :  epistaxis  ;  haematemesis  ;  intestinal  haemorrhage  ; 
haematuria.  Fortunately,  haemorrhage  from  the  broncho-pulmonary 
mucous  membrane  is  not  common,  except  in  cases  of  incipient  phthis- 
is. Haemorrhages  take  place  also  on  the  serous  surfaces,  and  haemor- 
rhagic  effusions,  the  result  of  inflammation,  are  not  infrequent  in  the 
pleura,  pericardium,  and  peritoneum.  Enlargement  of  the  spleen, 
often  to  a  considerable  extent,  occurs  in  a  portion  of  the  cases.  Al- 
buminuria is  present  in  the  severer  cases  very  often,  and  the  urine  is 
otherwise  changed  in  character  and  composition.  The  most  notable 
change  besides  the  albuminuria,  is  the  diminution,  not  only  in  the 
amount  of  urine  secreted,  but  in  the  relative  amount  of  its  solids. 

Complications. — The  periosteum,  cartilages,  and  joints  are  affected 
in  the  worst  cases.  Extravasations  take  place  under  the  periosteum, 
causing  a  painful  swelling,  which  may  take  on  an  inflammatory  char- 
acter if  the  extravasation  be  large.  The  epiphyses  of  the  long  bones 
become  swollen,  soften  somewhat,  and  may  be  detached  even.  Haemor- 
rhagic  effusions  occur  in  the  articulations,  causing  painful  swelling, 
inflammation,  and  fever.  Meningeal  haemorrhage  is  a  very  rare  acci- 
dent, but  haemorrhage  into  the  substance  of  the  brain  never  occurs. 
Extravasations  of  blood  also  take  place  in  the  anterior  chamber  of  the 
eye  and  under  the  conjunctiva.  Severe  inflammation  may  be  the 
result.     Hemeralopia,  or  night-blindness,  has  long  been  associated  with 


SCORBUTUS.  209 

scurvy,  but  cases  of  scurvy  are  without  it,  and  it  often  exists  quite 
apart  from  scurvy.  The  profound  alteration  in  the  fluids  and  solids 
of  the  body  caused  by  scorbutus  invites  attacks  of  other  maladies. 
A  frequent  complication  is  croupous  pneumonia,  and  a  cause  of  death 
in  many  cases.  Hoemorrhagic  infarctions,  usually  several,  sometimes 
are  also  found  in  the  lungs.  Ulcerative  endocarditis  and  haemorrhagic 
pericarditis  are  complications  which  quickly  cause  a  fatal  result. 

Diagnosis. — Until  the  characteristic  change  has  occurred  in  the 
gums,  on  the  skin,  etc.,  the  anaemia  of  scorbutus  is  not  distinguishable 
from  other  diseases  characterized  by  this  state.  When,  however,  the 
gums  swell,  and  there  are  petechise  on  the  skin,  and  indurations  be- 
neath, it  is  impossible  to  confound  it  with  any  other  malady. 

Course,  Duration,  and  Termination. — The  usual  course  of  scorbutus 
consists  in  the  prodromal  period,  the  fully  developed  attack  character- 
ized by  the  swollen  and  sloughing  gums,  the  hsemorrhagic  affections 
of  the  skin,  the  extravasations  into  the  subcutaneous  areolar  tissue  and 
muscles,  the  inflammatory  hsemorrhagic  exudations  of  the  serous  mem- 
branes, the  profound  cachexia,  and  the  period  of  restoration.  The 
duration  is  usually  jarotracted,  and  is  influenced  by  the  hygienic  sur- 
roundings. When  the  disease  is  fully  developed,  the  continuance  of 
the  causes  will  keep  it  in  action  and  increase  the  morbid  process, 
while  i^ecovery,  even  in  an  apparently  hopeless  condition,  takes  place 
promptly  when  the  proper  aliment  is  supplied.  The  earlier  the  ap- 
propriate means  of  cure  are  applied,  the  more  perfect  the  restoration. 
Serious  deformities  may  result  from  the  inflammations  of  the  muscles, 
bones  and  joints,  and  death  quickly  follows  the  lighting  up  of  pleu- 
ritis,  endocarditis,  peritonitis,  etc.  These  evil  results  only  occur  when 
the  disease  has  been  unusually  protracted  and  severe.  Death  usually 
results  from  hasmorrhages,  from  exhaustion,  from  a  serous  inflamma- 
tion, or  fi'om  pneumonia,  but  the  mortality  depends  almost  wholly 
on  the  failure  of  the  necessary  supplies,  and  not  on  the  virulence  of 
the  disease.  With  the  progress  of  knowledge,  scorbutus  is  becoming 
much  less  common.  No  longer  are  witnessed  the  frightful  cases  in 
armies,  on  shipboard,  and  in  prisons,  such  as  were  very  common  only 
a  century  ago. 

Treatment.  —  The  prophylaxis  as  well  as  treatment  of  scurvy, 
above  all  things,  necessitates  the  use  of  anti-scorbutic  food,  fresh  vege- 
tables of  all  kinds,  especially  the  potato  and  sauerkraut,  and  lime- 
juice.  In  the  English  navy,  lime-juice  is  most  depended  on  ;  but 
ships  and  bodies  of  troops  ai'e  also  supplied  with  "desiccated  vege- 
tables," the  ordinary  vegetables,  including  cabbage,  onions,  potatoes, 
etc.,  compressed  into  tablets  and  carefully  dried.  Desiccated  or  con- 
densed milk  is  also  utilized  for  the  same  purpose.  Whenever  attain- 
able, fresh  meats  are  extremely  serviceable,  and,  in  their  absence, 
canned  meats,  beef-juice,  and  similar  preparations,  can  be  made  to 
14 


210  DISEASES   OF   THE   BLOOD-FORMING   ORGANS. 

supply  their  place.  Yeast  has  been  found  by  Neumann  *  to  be  highly 
beneficial,  and  also  the  barm  of  beer.  Medicines  play  a  secondary 
part  in  the  treatment  of  scurvy.  In  accordance  with  Garrod's  and 
Hammond's  potassa  theory,  we  may  prescribe  cream-of-tartar  lemon- 
ade, to  be  drunk  freely.  Quinine  and  sulphuric  acid,  either  alone  or 
in  combination,  are  used  to  diminish  transudations  and  to  improve  the 
tone  of  the  system  in  general.  Tincture  of  the  chloride  of  iron  and 
ergot  are  given  to  arrest  haemorrhage.  There  can  be  no  doubt,  if  the 
author  can  depend  on  his  own  observation,  of  the  value  of  whisky  as 
a  remedy  for  the  scorbutic  state,  and  to  lessen  or  prevent  the  extrava- 
sations of  blood.  An  ounce  of  whisky  every  four  hours  is  generally 
the  most  useful  amount.  Turpentine  is  a  highly  efficient  stimulant 
and  hasmostatic  under  the  same  conditions,  and  is  the  best  dressing 
for  the  ulcers  in  the  skin.  Alum,  tannin,  subsulphate  of  iron,  and 
chloride  of  iron,  are  the  most  useful  local  styptic  applications  for  ar- 
resting epistaxis,  and  haemorrhage  from  superficial  wounds,  or  ulcers 
of  the  skin.  Ergotin  can,  at  the  same  time,  be  administered  by  the 
stomach.  Red  cinchona-bark  in  powder  is  an  excellent  dressing  for 
the  ulcers  of  the  skin.  As  the  various  manifestations  and  localizations 
of  the  disease  are  due  to  the  cachexia,  no  time  should  be  wasted  in 
treating  them,  but  every  effort  put  forth  to  improve  the  condition  of 
the  body  in  general. 


PURPURA— PURPURA  H.EMORRHAGICA— MORBUS  MAOULOSUS. 

Definition. — The  term  purpura  means  a  bluish-red  or  purplish  dis- 
coloration, produced  by  extravasation  of  blood ;  purpura  simplex  is 
applied  to  the  simplest  form  of  this  malady,  in  which  there  are  only 
minute  extravasations  in  the  skin  (petechise),  and  no  haemorrhages  into 
other  parts  ;  purpura  hmmorrhagica  indicates  a  condition  of  things  in 
which  not  only  petechiae  appear  in  the  skin,  but  ecchymoses,  vibices, 
and  hasmorrhages  occur.  Besides  the  variations  in  intensity  as  ex- 
pressed in  the  names  applied  to  the  disease,  there  are  differences  in 
character.  Although  a  very  large  proportion  of  cases  of  purpura, 
whether  simple  or  haemorrhagic,  are  entirely  free  from  fever,  there  are 
cases  of  both  forms  in  which  fever  is  present — the  febrile  form  (pur- 
pura febrilis).  There  are  other  cases,  complicated  with  rheumatism, 
one  or  several  joints  being  affected — rheumatic  purpura  (purpura 
rheumatica). 

Causes  and  Symptoms. — Purpura  is  not  limited  by  climate,  race,  sex, 
or  social  condition,  but  it  occurs  more  frequently  in  females,  and  is 
more  common  from  fifteen  to  twenty  than  at  any  other  age.  It  ap- 
pears to  be  strictly  sporadic.     Convalescents  from  fever  seem  to  be 

*  Imraermann,  op.  cit. 


PUEPURA.  21;!^ 

specially  liable  to  it.  The  disease  usually  begins  abruptly,  the  first 
manifestation  being  epistaxis.  In  a  few  cases  there  is  a  prodromal 
period,  of  a  few  days,  possibly  a  week,  in  which  there  are  some  languor 
and  inaptitude  for  exertion  of  any  kind,  sometimes  with  feverishness, 
sometimes  Avith  rheumatic  pains,  and  slight  swelling  of  the  joints, 
usually  the  ankles  and  knees.  The  next  symptom  is  the  occurrence  of 
petechioe  on  the  lower  extremities  and  body,  less  on  the  arms,  and 
rarely  on  the  face.  These  petechite  or  bluish-red  spots,  vary  in  size 
from  a  pin's-head  to  a  pea,  and  change  in  color  successively  from  blr- 
ish-red  to  greenish,  brown,  and  yellow.  As  successive  crops  come 
out,  the  appearance  of  the  skin  is  peculiar,  the  different  colors  of  dif- 
ferent ages  being  curiously  intermingled.  Slight  injuries,  blows  and 
contusions,  are  followed  by  extravasations,  bluish-red  spots  of  irregu- 
lar size  making  their  appearance.  So  long  as  the  disease  is  limited  to 
these  manifestations,  it  is  entitled  purpura  simplex  ;  but  hasmorrhage 
from  the  mucous  surfaces  is  very  common.  The  mucous  membrane 
of  the  mouth  is  a  not  unusual  source  of  haemorrhage,  but  the  spongy 
and  sloughing  gums  of  scurvy  are  entirely  wanting,  as  also  the  diph- 
theritic and  inflammatory  exudations.  Hssmorrhages  may  also  occur 
in  the  subcutaneous  areolar  tissue,  in  the  serous  cavities,  from  the  cere- 
bral meninges,  but  these  are  exceptional ;  whereas  the  hgemorrhages 
from  the  mucous  surfaces  is  the  special  feature,  and  may  be  the  only 
condition  present.  It  has  been  observed  a  few  times  that  the  haemor- 
rhages have  come  on  suddenly,  without  any  other  symptoms,  in  appar- 
ently healthy  and  vigorous  subjects,  and  without  impairing  the  general 
health  ;  usually,  however,  the  repeated  losses  of  blood  cause  an  extreme 
degree  of  ansemia,  manifested  by  pallor,  emaciation,  weakness  and 
breathlessness  on  slight  exertion,  faintness  on  assuming  the  erect  pos- 
ture, swollen  ankles,  etc.  Before  haemorrhages  occur,  the  condition 
of  the  blood  seems  normal;  but  in  the  further  progress  of  the  cases  the 
blood  becomes  watery,  the  white  corpuscles  increase  in  number  rela- 
tively, and  the  red  corpuscles  decrease,  but  the  coagulability  of  the 
blood  is  at  no  period  lost.  Besides  the  presence  of  blood  on  the 
mucous  surfaces  and  on  some  of  the  serous  membranes,  there  are  j^ost- 
mortera  changes  to  be  noted.  The  haemorrhages  are  mere  extravasa- 
tions, and  under  no  circumstances  inflammatory.  The  disease  may 
therefore  be  regarded  as  a  ^^ transitory  hcernorrhagic  diathesis''''  (Im- 
mermann).  An  important  result  of  the  disease,  due  directly  to  the 
haemorrhages,  but  persisting  after  they  have  ceased,  is  anaemia.  It  is 
in  a  high  degree  probable  that  the  anaemia,  which  is  increased  by  the 
haemorrhage,  is  also  a  principal  factor  in  their  causation.  Urticaria  is 
another  complication,  and  seems  to  be  associated  with  stomach  de- 
rangement. A  much  more  rare  accident  is  the  occurrence  of  slough- 
ing and  perforation  of  the  intestines,  produced^  by  haemorrhagic  ex- 
travasations into  the  tunics  of  the  bowel. 


212  DISEASES   OF  THE   BLOOD-FORMING   ORGAXS. 

Course,  Duration,  and  Termination. — The  -vrhole  course  of  the  dis- 
ease includes  the  prodromal  period,  the  purpura  simplex,  the  period  of 
hcemorrhage,  and  the  subsequent  antemia.  The  duration  is  influenced 
materially  by  the  number  and  amount  of  the  haemorrhages.  An  ordi- 
nary case  will  last  two  or  three  weeks,  but  when  there  are  repeated 
haemorrhages  the  disease  may  continue  for  several  months.  Although 
most  cases  recover,  death  sometimes  happens  from  exhaustion,  from 
internal  haemorrhage,  from  some  intercurrent  malady,  and  from  jDer- 
foration  of  the  bowel. 

Diagnosis. — Purpura  may  be  confounded  with  scorbutus,  hemo- 
philia, progressive  pernicious  ansemia,  leucocythemia,  and  cerebro- 
spinal meningitis.  From  scuiwy  it  is  differentiated  by  the  absence 
of  changes  in  the  gums,  of  the  indurations  of  the  subcutaneous  areolar 
tissue  and  of  the  muscles,  of  the  hemorrhagic  inflammation  of  the 
serous  membranes,  etc.  From  hemophilia  the  distinction  is  made  by 
reference  to  the  history,  especially  the  heredity,  by  the  period  of  life, 
by  the  bleeding  from  trivial  wounds,  so  characteristic  of  hemophilia, 
and  not  of  purpura.  The  distinction  of  purpura  from  progressive  per- 
nicious anemia  rests  on  the  fact  that  in  the  former  the  anemia  is  pro- 
duced by  the  bleeding,  in  the  latter  the  bleeding  comes  on  afterward 
and  is  due  to  the  poverty  of  blood.  From  leucocythemia  the  distinc- 
tion is  made  by  the  enlarged  spleen  and  enlarged  lymphatics,  with  the 
growth  of  which  a  marked  degree  of  anemia  is  coincident,  and  to 
which  the  hemorrhagic  tendency  succeeds.  The  initial  symptoms  of 
cerebro-spinal  meningitis  may  be  almost  identical  with  those  of  pur- 
pura :  purplish  spots,  pains  in  the  joints,  with  some  slight  feverishness, 
but  in  a  day  or  two  the  occurrence  of  nervous  phenomena  decides  the 
question. 

Prognosis. — Most  of  the  cases  terminate  in  recovery.  A  guarded 
opinion  must  be  expressed  when  the  hemorrhages  recur  again  and 
again,  and  when  the  disease  occurs  in  broken-down  subjects. 

Treatment. — The  usual  treatment  consists  in  the  administration  of 
the  mineral  acids,  especially  the  sulphuric,  and  of  the  preparations  of 
iron,  especially  the  tincture  of  the  chloride.  "With  these  remedies 
must  be  conjoined  a  suitable  dietary,  fresh  air,  sunshine,  and  moderate 
exercise.  If  constipation  be  present,  the  most  appropriate  laxative  is 
sulphate  of  magnesia  with  dilute  sulphuric  acid.  If  hemorrhages  that 
are  threatening  come  on  with  a  strong  pulse,  flushed  face,  headache, 
and  excitement,  digitalis,  quinia,  and  ergotin  are  the  appropriate  medi- 
caments. If  there  be  weakness  and  debility,  quinine  and  alcoholic 
stimulants  moderately  should  be  prescribed.  The  local  means  for 
arresting  bleeding  consist  in  subsulphate  of  iron,  tannin,  alcohol,  ice, 
or  it  may  be  hot  water,  which  is  sometimes  more  effective  than  cold. 
For  the  after-anemia  iron  should  be  pushed. 


ANEMIA.  213 

AN  JEJMIA—  OLIG-ffiMIA. 

Definition. — The  term  anoimia,  which  signifies  want  of  blood,  con- 
sists of  a  deficiency  of  its  nutritive  constituents.  Oligmmia,  which 
signifies  poverty  of  blood,  is  a  more  correct  term  ;  but  the  former  is 
too  firmly  fixed  by  usage  to  permit  a  change.  Although  fi'om  the 
etymological  point  of  view  aniemia  must  be  used  to  indicate  a  defi- 
ciency of  blood,  yet,  by  common  usage,  it  is  understood  to  mean  pov- 
erty of  the  blood,  and  in  that  sense  is  erajiloyed  in  this  work. 

Causes. — The  tendency  to  ansemia  is  influenced  by  sex,  age,,  and 
peculiarities  of  individual  constitution.  The  female  sex  is  more  liable 
than  the  male,  for  the  reason  probably  that  the  former  are  by  nature 
less  endowed  with  the  nutritive  constituents  of  blood.  Compared  to 
the  body-weight,  and  still  more  decidedly  by  sex,  the  blood  of  women 
contains  fewer  red  corpuscles,  more  water,  and  less  albumen  and  salts, 
than  the  blood  of  men.  While  the  average  number  of  red  globules 
in  the  blood  of  healthy  adult  males  is  141 '1  per  1,000  parts,  in  the 
healthy  adult  female  it  is  127*2  (Becquerel  and  Rodier*).  The  ex- 
tremes of  life — youth  and  old  age — are  more  liable  to  anaemia  than  the 
period  of  maturity.  In  early  life  the  needs  of  the  growing  organism 
are  such  as  to  require  the  utmost  amount  of  pabulum  from  the  blood  ; 
the  interchanges  are  more  rapid,  the  consumption  of  material  greater, 
and  hence  the  more  ready  development  of  anaemia  if  other  circum- 
stances coincide.  In  old  age,  on  the  other  hand,  the  productivity  is 
diminished,  and  hence  the  waste  may  easily  exceed  the  demand  if 
there  be  any  disturbance  either  in  the  preparation  of  materials  for  the 
blood  or  in  the  retrograde  metamorphosis  of  the  tissues.  There  are 
those  also  who  have  a  natural  tendency  to  anaemia,  a  peculiar  type  of 
constitution.  They  are  in  a  condition  the  opposite  of  plethora,  are 
deficient  in  the  amount  and  quality  of  blood,  and  seem  to  be  unable  to 
produce  it  effectively.  Sometimes  they  are  persons  of  full  habit,  but 
possess  a  lax  fiber,  and  are  pale  and  weak. 

A  powerful  exciting  cause  of  anaemia  is  an  insufficient  supply  of 
food.  Again,  the  food  being  abundant,  ansemia  may  be  the  result  of 
poor  digestion,  and  faulty  and  imperfect  assimilation.  The  food  abun- 
dant, and  the  primary  assimilation  active,  anaemia  may  result  because 
of  a  deficiency  in  the  supply  of  oxygen  to  complete  the  cycle  of  pro- 
cesses terminating  in  healthy  blood.  When  the  products  of  digestion 
are  pouring  into  the  blood,  oxygen  is  needed  to  burn  off  the  effete, 
excessive,  or  improper  materials,  and  to  perfect  the  preparation  of  the 
new  materials.  Light  is  also  necessary  to  this  process.  Moderate 
exercise,  by  increasing  the  rate  of  organic  movements  and  the  con- 
sumption of  oxygen,  favors  the  preparation  of  the  blood  and  improves 

*  "  Pathological  Chemistry,"  translated  by  Dr.  S.  T.  Speer.  London :  Churchhill, 
1857. 


214  DISEASES  OF   THE  BLOOD-FORMING   ORGANS. 

its  quality.  The  absence  or  imperfect  supply  of  food,  light,  air,  and 
exercise,  impairs  the  vital  processes  and  induces  anseraia.  Excessive 
exertion  and  fatigue,  by  the  over-consumption  of  material,  directly 
contribute  to  the  production  of  the  anaemic  state.  Heat  acts  similarly, 
in  that  prolonged  high  temperature  increases  the  rate  of  circulation  and 
the  interchanges  of  waste  and  repair,  while  at  the  same  time  it  inter- 
feres with  supply  by  lessening  the  appetite  and  the  digestion.  Fre- 
quent repetition  of  the  sexual  orgasm,  profuse  menstrual  flow,  pro- 
longed lactation,  hsemorrhages,  are  very  powerful  causes  of  anaemia. 
Diseases  of  the  organs  concerned  in  nutrition,  notably  the  digestive 
organs,  malignant  growths,  albuminuria,  the  slow  absorption  of  various 
mineral,  vegetable,  and  gaseous  poisons,  and  numerous  pathological 
processes,  either  produce  or  are  accompanied  by  ansemia  ;  but  in  this 
relation  the  position  of  ansemia  is  quite  secondary. 

Pathological  Anatomy. — The  changes  found  post  mortem  in  ansemia 
from  haemorrhage  are  simply  the  appearances  due  to  an  exsanguine 
condition  of  all  the  organs  and  tissues.  They  are  paler,  drier,  more 
compact,  and  free  from  blood.  If  death  has  been  preceded  by  a  wast- 
ing malady,  not  only  is  there  the  condition  of  bloodlessness,  but  the 
body  is  shunken,  the  subcutaneous  fat  has  disappeared,  the  muscles  are 
thin,  and  the  serous  cavities  contain  more  or  less  fluid.  Patches  of 
fatty  degeneration  occur  in  the  muscular  tissue  of  the  heart — chiefly 
in  the  papillary  muscles — and  to  the  eye  present  the  appearance  of  yel- 
low spots  and  strise.  A  similar  (i.  e.,  fatty)  change  is  to  be  found  in 
the  intima  of  the  great  vessels,  notably  the  aorta.  Fatty  change  also 
takes  place  in  the  gland  epithelium  of  various  organs — the  kidney 
epithelium,  the  hepatic  cells,  the  gastric-gland  epithelia,  etc.  The  blood 
has  a  brighter  tint  than  in  the  normal  condition,  due  to  a  diminution  in 
the  number  of  red-blood  globules,  and  in  the  quantity  of  hsemoglobin. 
In  the  ansemia  due  to  loss  of  blood,  the  amount  remaining  after  death 
is  much  below  the  normal ;  under  other  circumstances,  the  diminution 
may  be  but  slight.  The  blood  is  also  thinner,  and  has  less  power  of 
coagulation,  the  clot  lacking  in  firmness,  whence  it  must  be  concluded 
that  the  fibrino-plastic  substance  and  the  fibrinogen  are  below  normal. 

Symptoms. — The  simplest  and  purest  form  of  ansemia  is  that  caused 
by  sudden  and  considerable  loss  of  blood,  as  from  wounds  of  arteries, 
unavoidable  and  post-partum  haemorrhage,  etc.  The  symptoms  are 
eminently  characteristic  :  the  skin  becomes  waxy  white  ;  the  sclerotic 
pearly  and  glistening,  eyes  sunken ;  the  face  ghastly  and  shrunken ; 
the  lips  pallid  and  bluish  and  retracted  over  the  teeth  ;  the  nose  pointed 
and  cold ;  the  finger-tips  white,  waxy,  and  cold  ;  the  surface  of  the 
body  is  cold,  and  the  temperature  reduced  below  the  normal ;  the 
pulse  is  small,  very  quick,  exceedingly  feeble,  and  may  cease  to  be  felt 
at  the  wrist ;  actual  fainting  may  occur  ;  consciousness  restored,  faint- 
ing maybe  repeated,  and  this  may  occur  many  times  ;  the  attacks  of 


ANiEMIA.  215 

syncope  may  be  accompanied  by  epileptiform  convulsions  as  in  ani- 
mals bled  to  death  (Kussmaul  and  Tenner  *) ;  death  may  ensue  in  the 
syncope,  or  there  may  be  a  gradual  restoration,  the  first  change  for  the 
better  consisting  in  a  return  of  the  pulse  at  the  wrist,  followed  by 
warmth  of  the  surface.  But  the  weakness  is  yet  extreme,  and  fainting 
occurs  from  the  least  exertion  ;  or,  when  any  effort  is  made,  the  face 
flushes,  the  heart  beats  rapidly,  there  is  much  oppression  of  the  chest, 
and  a  sense  of  utter  exhaustion.  Excessive  thirst  is  one  of  the  immedi- 
ate results  of  loss  of  blood,  but  the  appetite  for  solid  food  returns  very 
slowly.  The  urine  is  necessarily  small  in  quantity  after  haemorrhage, 
but  the  relative  proportion  of  urea  is  increased.  When  restoration  is 
taking  place,  the  urea  is  less,  the  specific  gravity  of  the  urine  falls 
below  the  average  standard,  until  the  normal  state  is  reached.  The 
most  common  form  of  anaemia  is  that  induced  by  wasting  discharges 
— prolonged  lactation,  for  example — by  disturbances  in  the  function 
of  nutrition — primary  and  secondary  assimilation — by  the  eachexiae — 
notably  the  malarial.  This  form  of  anaemia  may  be  called  chronic, 
while  that  already  discussed  is  either  acute  or  subacute.  In  chronic 
anaemia  there  exist  pallor,  or  an  earthy  hue  or  fawn  color  of  the  skin, 
wasting  to  a  greater  or  less  extent,  by  disappearance  of  the  subcuta- 
neous fat,  and  a  flabby  state  of  the  muscles  :  the  skin  is  wrinkled,  dry, 
and  inelastic,  the  hair  and  nails  appear  dull  and  lusterless  ;  the  temper- 
ature of  the  surface  below  normal ;  the  cutaneous  circulation,  the  ten- 
sion of  the  arteries,  and  the  force  of  the  cardiac  contraction  lowered  ; 
the  anaemia  hruit  audible  at  the  base  of  the  heart  and  over  the  great 
venous  trunks  ;  sometimes  a  haemorrhagic  tendency  develops ;  the 
function  of  digestion  is  wanting  in  energy,  the  appetite  capricious,  the 
bowels  constipated  ;  the  urinary  secretion  is  rather  scanty,  and  may 
contain  albumen,  etc.  ;  the  sexual  system  is  depressed,  both  male  and 
female,  and,  while  the  sexual  appetite  is  lessened  in  the  male,  amenor- 
rhoea  is  present  in  the  female,  or  there  may  be  menorrhagia.  Not  all 
anaemic  persons  become  paler  by  reason  of  diminished  vascularity  of 
the  skin;  those  of  dark  complexion  and  the  dark-skinned  become  darker. 
The  emaciation,  or  at  least  the  lessened  fullness  and  roundness  of  the 
form  due  to  anaemia,  may  be  supplanted  by  cedema,  produced  by  the 
changes  in  the  composition  of  the  blood.  When  the  diminution  of 
albumen  reaches  a  certain  point,  the  fluid  normally  contained  in  the 
tissue  is  not  taken  up  by  the  blood-vessels,  whence  more  or  less  cedema 
results,  and,  under  the  same  circumstances,  accumulation  of  serum 
takes  place  in  the  serous  cavities.  In  this  process  there  necessarily 
exist  both  "hypalbuminosis"  and  "hydraemia" — the  former  meaning 
a  diminished  amount  of  albumen ;  the  latter,  an  increased  amount  of 
water.     The  hypalbuminosis  is  the  most  important  factor  in  the  pro- 

*  "  On  tbe  Nature  and  Origin  of  Epileptiform  Convulsiona,  caused  by  Profuse  Bleed- 
ing, etc."     Sydenham  Society  translation. 


216  DISEASES   OF   THE   BLOOD-FORMING   ORGANS. 

duction  of  the  wasting  or  marasmus  of  anaemia.  Not  all  parts  lose  in 
weight  uniformly — the  fatty  tissue  comes  first,  and  next  the  spleen, 
liver,  and  voluntary  muscles;  and,  as  respects  the  muscular  system,  those 
waste  least  that  are  kept  at  work,  as  the  heart  and  respiratory  muscles. 
The  weakness  of  the  muscular  system,  which  is  so  prominent  a  symp- 
tom in  anaemia,  is  due  largely  to  the  diminished  production  of  force, 
rather  than  to  changes  in  the  muscles  themselves.  The  poor  quality 
of  the  blood  and  the  inactivity  of  the  tissue-changes  are  the  causes 
of  the  lessened  evolution  of  force.  A  temperature  below  the  normal 
is  another  result  of  the  same  causes.  Among  the  most  important  of 
the  symptomatic  disturbances  of  ■  anaemia  are  those  of  the  nervous 
system.  The  organs  of  special  sense  are  peculiarly  alive  to  external 
impressions,  and  hence  loud  sounds,  bright  lights,  and  sharply  sapid 
substances,  make  an  unpleasant  impression.  The  sensory  and  motor 
apparatus  are  similarly  affected.  Hyperaesthesia  and  hyperalgesia — 
neuralgia — ^are  among  the  most'  disagreeable  of  the  symptoms  which 
occur  dui'ing  ansemia.  Hysterical  seizures,  epileptoid  attacks,  are  also 
results  of  an  imperfect  nutritive  supply  ("  anaemia  of  the  brain  ").  When 
the  antemia  is  extreme,  as  in  cases  of  inanition,  or  from  any  cause,  there 
is  usually  delirium,  it  may  be,  having  a  violent  maniacal  character,  or 
low-muttering,  or  cheerful,  busy  delirium.  The  anaemia  may  result  in 
syncope  with  temporary  loss  of  consciousness — attacks  frequently  due 
to  mere  enfeeblement  of  the  heart's  action.  As  regards  the  condition 
of  the  organs  of  circulation,  it  is  to  be  noted  that  the  cardiac  movements 
are  feeble,  the  sounds  muffled  and  indistinct,  and  the  arterial  tension  low. 
The  diminished  power  of  the  heart  to  move  the  blood  leads  to  stasis 
in  the  venous  system,  which  may  result  disastrously  by  oedema  of  the 
lungs,  or  hypostatic  pneumonia,  or  by  thromboses.  More  or  less  diffi- 
culty of  breathing  is  a  constant  symptom,  but  there  may  be  extreme 
dyspnoea  when  some  sudden  effort  is  made.  The  impaired  breathing 
power  is  the  product  of  several  factors  :  1.  Of  the  increased  irritabil- 
ity of  the  respiratory  centers  ;  2.  Of  imperfect  depuration  of  carbonic 
acid,  and  insufficient  supply  of  oxygen. 

Course,  Duration,  and  Termination. — The  course  of  anaemia  is  that 
of  the  malady  with  which  it  is  associated  or  on  which  it  is  dependent. 
If  due  to  haemorrhage,  or  some  sudden  accident,  it  is  acute,  but  the 
usual  course  is  chronic.  It  has  no  defined  duration,  and  is  in  no  sense 
a  self -limited  disease.  The  progress  of  recovery  is  influenced  by  age, 
sex,  and  the  recuperative  powers  of  individuals.  While  women  bear 
loss  of  blood  better  than  men,  they  possess  less  restorative  energy. 
The  hygienic  circumstances  and  the  social  condition  are  important 
elements  in  the  process  of  reconstruction — for  those  who  are  most 
favorably  placed  have  the  best  chance  of  recovery  and  the  least  delay 
in  convalescence.  Anaemia  may  result  in  death,  in  recovery,  or  in 
incomplete  recovery.     When  the  anaemia  has  been  extreme,  and  the 


AN.EMIA.  217 

destruction  of  red-blood  globules  great,  recovery  is  rarely,  if  ever,  com- 
plete, and  the  patient's  bodily  vigor  remains  more  or  less  below  the 
normal. 

Prognosis. — The  cause  of  the  malady  and  its  associated  states  enter 
largely  into  the  question  of  prognosis.  When  the  ansemia  is  simple, 
due,  for  example,  to  sudden  loss  of  blood,  or  to  prolonged  lactation, 
or  to  malarial  infection,  or  to  sexual  disorders,  or  to  diseases  of  diges- 
tion— all  of  which  are  perfectly  remediable — the  prognosis  is  favor- 
able. When,  however,  anaemia  has  been  produced  by  excessive  loss 
of  blood,  and  a  condition  of  extreme  debility  has  persisted  for  weeks  ; 
when  associated  with  great  mobility  of  the  nervous  system,  and  with 
protracted  amenorrhoea,  the  prognosis  must  be  guarded  in  respect  to 
complete  recovery.  When  anaemia  is  associated  with  cancer,  albumi- 
nuria, suppuration  of  bone,  amyloid  degeneration,  phthisis,  scrofula, 
etc.,  the  prognosis  is  unfavorable. 

Treatment. — As  the  condition  to  be  remedied  consists  in  an  im- 
poverished state  of  the  blood,  obviously  treatment  must  be  directed 
to  the  organs  concerned  in  the  elaboration  of  blood  ;  the  organs  of 
digestion,  including  the  liver  and  pancreas,  and  the  organs  for  the 
production  of  the  corpuscular  elements — the  spleen  and  lymphatic 
system.  The  first  step  consists  in  the  rectification  of  any  existing  dis- 
ease of  the  digestive  apparatus,  if  remediable  ;  the  second,  in  the  sup- 
ply of  suitable  aliment  ;  the  thii-d,  in  the  administration-  of  certain 
medicines  needed  in  the  construction  of  the  blood  ;  and,  fourth,  in  the 
admission  of  air,  sunlight,  and  suitable  exercise  to  an  important  place 
in  the  treatment,  for  these  are  required  to  perfect  the  final  stage  of 
the  conversion  of  aliment  into  blood.  If  the  digestion  is  feeble  by 
reason  of  a  deficiency  of  gastric  juice,  muriatic  acid  and  pepsin  should 
be  administered  after  meals.  If  there  be  torpor  merely,  this  may  be 
overcome  by  the  use  of  nux-vomica  tincture,  or  the  simple  or  aromatic 
bitters — these  acting  as  local  stimulants  to  the  stomach-glands.  If  the 
appetite  is  languid  and  the  stomach  is  equal  to  the  digestion  of  the  ali- 
ment taken,  it  will  sufiice  to  depend  on  the  third  group  of  remedies. 
A  suitable  supply  of  properly  proportioned  food  is  of  the  very  highest 
importance.  The  albuminous  or  nitrogenous  constituents — fresh  animal 
food,  eggs,  milk,  etc. — are  the  most  necessary,  but  vegetables  and 
fruits  are  also  useful.  If  the  digestive  organs  support  food  badly,  it 
should  be  given  in  small  quantity  at  short  intervals,  and,  if  solid  food 
can  not  be  managed  by  the  stomach,  beef-juice  and  milk  can  be  given 
instead.  The  blood  plasma  may  also  be  supplied  directly  by  the  rectal 
injection  of  defibrinated  blood  on  the  plan  of  Dr.  Smith,  of  Xew  York, 
A^hich  is  a  most  important  addition  to  our  resources  in  the  treatment 
of  anaemia.  A  moderate  quantity  of  alcoholic  food  is  also  highly  ser- 
viceable— say,  a  tablespoonful  of  whisky  three  time  a  day — but  it 
should  always  be  remembered  that  a  taste  for  alcoholic  beverages  is 


218  DISEASES   or   THE  BLOOD-FORMING   ORGANS. 

quickly  formed  under  these  circumstances.  The  medicines  required 
are  those  actually  used  in  reconstruction  of  the  blood,  viz.,-  iron,  man- 
ganese, and  the  phosphates.  As  iron  and  manganese  exist  together 
in  the  blood  (1  to  40),  and  also  throughout  nature,  it  is  very  useful 
to  follow  this  indication  and  administer  them  together.  There  is 
another  view  of  the  utility  of  iron — promulgated  chiefly  by  Brown- 
Sequard — that  it  acts  solely  by  increasing  digestion,  and  that  the  food 
taken  in  increased  quantity  under  its  use  contains  sufficient  iron  to 
supply  the  requirements  of  the  blood  ;  but  the  former  view  is  that 
chiefly  entertained.  The  saccharated  carbonate  of  iron  and  manga- 
nese is  an  excellent  preparation,  or  the  dried  sulphates  of  iron  and 
manganese  may  be  prescribed  in  pill-form,  with  or  without  extracts  of 
mix  vomica,  gentian,  or  calumba.  The  question  of  the  comparative 
utility  of  the  vegetable  or  mineral-acid  compounds  of  iron  frequently 
arises.  Notwithstanding  the  jDaradoxical  character  of  the  statement, 
it  is  generally  true  that  the  more  irritating  and  astringent  preparations 
are  better  borne,  and  they  are  certainly  more  effective.  Next  to  iron 
and  manganese  are  the  phosphates,  especially  the  phosphate  of  lime. 
In  the  anosmia  of  lactation  there  is  a  very  marked  deficiency  in  the 
quantity  of  phosphate  of  lime,  and  in  all  forms  more  or  less  reduction 
of  the  proper  amount  of  this  substance.  The  sirup  of  the  lacto-phos- 
phate  is  the  best  form  for  the  administration  of  this  agent,  if  well 
and  genuinely  prepared.  Pyrophosphate  of  iron  may  be  given  with 
the  phosphates,  as  compound  sirup  of  the  phosphates  ;  or  the  elixir 
of  the  phosphate  of  iron,  quinine,  and  strychnine  may  be  prescribed 
under  the  same  indications. 

When  purpura,  or  the  hsemorrhagic  diathesis,  or  allied  states  of  the 
blood  exist,  great  advantage  is  derived  from  the  conjoint  administra- 
tion of  ergot  or  digitalis  with  quinine  ;  for  iron  is  not  well  borne 
when  the  hsemorrhagic  tendency  exists,  although  the  blood  may  be 
deficient  in  this  constituent.  Among  the  remedies  for  promoting  the 
nutrition  of  the  body,  cod-liver  oil  takes  a  high  place.  It  is  usefully 
administered  with  the  phosphates,  especially  in  those  cases  in  which 
anfemia  is  associated  with  impaired  nutrition  of  the  nervous  system, 
and  lowering  of  the  general  nutrition  in  cases  of  pulmonary  disease. 
In  the  ansemia  produced  by  phosphorus,  carbonic-acid  narcosis,  coal- 
gas  poisoning,  etc.,  transfusion  has  been  successfully  employed.  Unin- 
jured new  elements  introduced  into  the  veins,  the  condition  of  ansemia 
is  at  once  removed.  The  operation  of  immediate  transfusion  of  human 
blood  is  alone  justifiable  under  these  circumstances,  for  lamb's  blood 
will  not  functionate  properly.  When  the  food  is  undergoing  final  con- 
version into  blood,  the  oxygen  of  the  air  is  necessary  to  complete  the 
changes.  Hence  some  exercise,  short  of  fatigue,  should  be  taken 
about  three,  hours  after  the  meals,  for  at  this  time  the  products  of 
digestion  are  pouring  into  the  blood,  and  then  the  oxygen  is  espe- 


CHLOROSIS.  219 

cially  needed.  Moderate  exercise  eflEects  a  proper  distribution  of  the 
blood  in  the  body,  increases  the  absorption  of  oxygen,  and  the  excre- 
tion of  carbonic  acid  and  urea.  In  proper  limits  exercise  promotes 
the  metamorphosis  of  tissue,  and  is  therefore  serviceable  in  ansemia, 
but,  carried  to  fatigue,  waste  is  greater  than  repair.  The  method  of 
combined  rest,  massage,  faradization,  and  forced  feeding,  practiced  by 
Weir  Mitchell,*  is  extremely  useful  in  these  cases,  and  Avill  often  suc- 
ceed when  other  means  fail. 


CHLOROSIS. 

Definition. — Chlorosis  and  ansemia  are  usually  regarded  as  identical 
disorders,  but  they  differ  sufficiently  to  be  treated  separately.  The 
peculiarities  of  chlorosis  are  simply  referred  to  the  sexual  condition, 
and  it  is  therefore,  according  to  this  view,  an  ansemia  occurring  in  girls 
about  the  period  of  puberty.  The  term  chlorosis  relates  to  the  pecu- 
liar tint  the  complexion  assumes  in  this  disease,  and  in  common  lan- 
guage it  is  designated  "  green-sickness." 

Etiology. — Chlorosis  is  a  disorder  of  the  female  sex  almost  exclu- 
sively, and  those  cases  occurring  in  males  are  examples  of  modified 
ansemia.  Puberty,  or  the  period  of  sexual  evolution,  is  the  time  of 
life  when  this  disorder  develops — from  the  fifteenth  to  the  twentieth 
year.  An  inherited  disposition  seems  to  exist  in  many  cases,  for  no- 
thing is  more  common  than  the  references  of  the  mother  to  her  own 
experience  when  the  daughter  betrays  the  first  signs  of  the  malady. 
The  type  of  constitution  which  is  thus  transmitted  is  distinctly  of 
lowered  vitality — "  the  gelatinous  descendants  of  albuminous  parents  " 
is  the  apt  phi-ase  descriptive  of  the  constitutional  state.  These  sub- 
jects are  light,  fair,  full,  round,  but  white,  having  blue  eyes,  soft  tis- 
sues, and  feeble  muscles.  Menstrual  irregularities  seem  closely  asso- 
ciated with  chlorosis,  either  as  cause  or  effect.  According  to  Virchow, 
abnormal  narrowness  of  the  aorta  is  an  important  factor.  If  an  hered- 
itary predisposition  exist,  or  congenital  defects  in  the  vascular  system, 
the  ordinary  contingencies  of  social  life  may  suffice  to  develop  it — es- 
pecially the  cultivation  of  the  emotional  life — but  it  occurs  quite  inde- 
pendently of  erotic  sentimentality.  On  the  other  hand,  this  condition 
of  the  system  comes  on  without  any  apparent  cause,  or  spontaneously. 
Hammond,  who  has  made  an  elaborate  study  of  chlorosis  ("Journal 
of  Psychological  Medicine "),  maintains  that  it  is  an  affection  of  the 
nervous  system,  the  blood-changes  being  secondary. 

Pathological  Anatomy. — The  body  is  fairly  well  nourished,  and  the 
subcutaneous  fat  pretty  well  distributed.  The  organs  are  generally 
pale.    The  serous  cavities  contain  but  little  fluid,  and  there  is  no  oedema 

*  "  Fat  and  Blood,  and  how  to  make  them." 


220  DISEASES  OF  THE  BLOOD-FORMIXG  ORGANS. 

of  the  inferior  extremities.  The  most  important  change  occurs  in  the 
blood,  and  consists  in  a  diminution  of  the  red  corpuscles.  This  can  now 
be  readily  detei-mined  by  actual  count,  using  the  haemacytometer,  as 
modified  by  Gowers,  for  this  purpose.  As  the  u'on  of  the  blood  is  re- 
duced in  this  disease,  it  is  probable  that  the  diminished  staining  power, 
which  is  so  consf)icuous  an  alteration,  is  due  as  well  to  diminution  of 
the  hrematin  as  to  loss  of  corpuscles.  In  chlorosis  the  albuminates 
and  the  leucocytes  are  not  diminished,  unless  an  anaemia  develops  in 
the  course  of  the  former,  when  the  alterations  peculiar  to  the  latter  are 
superadded.  Neither  is  the  volume  of  the  blood  apparently  reduced. 
We  owe  to  Yirchow  the  important  fact  that  in  recurrent  and  persistent 
chlorosis,  abnormalities  exist  in  the  vascular  system  :  the  aorta  and 
arterial  system,  generally,  are  smaller  in  caliber,  and  thinner,  the  in- 
tima  having  a  "  trellis-like  "  arrangement ;  and  the  tunics  of  the  ves- 
sels are  affected  by  fatty  degeneration  in  spots,  and  striae  of  a  yellowish 
color,  especially  the  intima.  These  spots  are  found  in  greatest  numbers 
about  the  origin  of  the  ascending  aorta,  and  on  close  examination  are 
found  to  be  a  collection  of  minuter  spots,  each  corresjjonding  to  a 
connective-tissue  corpuscle,  which  is  advanced  in  fatty  degeneration. 
The  heart  may  be  normal,  may  be  abnormally  small,  may  be  somewhat 
hypertrophied,  but  the  alterations  of  this  organ  are  not  constant.  The 
spleen,  the  lymjDhatics,  and  the  marrow  of  bones,  are  not  affected  in 
any  way. 

Symptoms. — Girls  about  the  period  of  puberty  are  the  subjects 
of  chlorosis.  "With  or  without  disorders  of  menstruation,  the  affected 
person  experiences  a  change  in  her  feelings,  and  becomes  morose  and 
despondent,  or  capriciously  vibrates  from  an  extreme  of  high  spirits 
to  corresponding  dej)ression,  but  low  spirits  is  the  habitual  state  of  the 
largest  number.  There  is  no  reason  to  believe  that  erotic  feelings  are 
mixed  up  with  the  gloomy  fancies  which  dominate  the  mind,  but  nym- 
l^homania  is  in  rare  instances  present  as  a  symptom.  Hysterical  mani- 
festations may  also  occur,  but  do  not  .constitute  a  necessary  part  of 
the  malady.  As  respects  the  actual  condition  of  the  sexual  organs, 
there  are  two  forms  of  derangement  which  happen  in  chlorosis  :  there 
are  the  amenorrhoeic  form  and  the  menorrhagic  form — cases  in  which 
the  menstrual  flow  is  absent ;  cases  in  which  the  flow  is  excessive. 
After  an  attack  of  menorrhagia,  or  after  the  failure  of  the  flow  to  ap- 
pear, the  changes  in  the  mental  state  above  mentioned  manifest  them- 
selves. Then  the  complexion  changes.  Fair-haired  and  white-skinned 
girls  (blondes)  become  pallid,  and  waxy,  and  puffy,  but  without 
oedema ;  dark-haired  and  dark-skinned  girls  (brunettes)  assume  a 
muddy,  grayish  coloration,  with  bluish-black  rings  under  the  eyes  ; 
the  sclerotic  being  pearly  and  glistening,  and  the  mucous  membrane 
of  the  mouth  pallid.  There  is  present,  constantly,  a  strong  feeling 
of  fatigue,  and  the  least  exertion  causes  weariness,  while  strong  mus- 


CHLOROSIS. 


221 


cular  effort  induces  exhaustion.  Muscular  effort  of  any  kind  starts 
the  heart  into  tumultuous  action,  and  brings  on  difficult  breathing  and 
a  sense  of  oppression.  The  anaemic  bruit  heard  at  the  base,  and  over 
the  great  vessels,  exists  in  chlorosis  as  in  anaemia.  The  pulse  is  rather 
full,  but  soft,  the  action  of  the  heart  irregular,  the  breathing  not  rhyth- 
mical, and  a  dry,  barking,  or  noisy  cough  is  not  unfrequently  present. 
The  appetite  is  usually  capricious — now  satisfied  with  difficulty,  now 
indifferent  to  food,  but  characterized  by  sudden  desire  for  unusual  arti- 
cles, or  by  craving  for  pickles,  slate-pencils,  chalk,  etc.  Attacks  of 
cardialgia  are  frequent  and  severe,  and  may  indicate  the  presence  of  a 
gastric  ulcer — a  not  infrequent  complication  of  chlorosis. 

Course,  Duration,  and  Termination. — The  course  of  chlorosis  is  af- 
fected by  the  social  circumstances,  and  the  treatment  still  more,  by 
the  presence  of  the  changes  described  in  the  vascular  system.  There 
are  several  important  complications  which  affect  the  behavior  of  chlo- 
rosis. The  first  is  anaemia,  the  development  of  which  increases  the 
gravity  and  adds  to  the  duration.  Phthisis  develops  in  a  considerable 
proportion  of  the  cases,  and  in  part  doubtless  because  of  the  narrow- 
ing of  the  aorta.  Perforating  ulcer  of  the  stomach  is  an  occasional 
and  very  fatal  complication.  The  explanation  of  its  relation  to  chlo- 
rosis is,  probably,  the  existence  of  fatty  change  in  the  intima  of  a 
stomach- vessel,  thrombosis,  and  rapid  solution  of  the  mucous  mem- 
brane. Chlorotic  subjects — those  affected  with  the  changes  in  the 
tunics  of  the  arteries,  certainly — are  very  liable  to  attacks  of  endocar- 
ditis. Yirchow,  to  whom  we  owe  our  knowledge  on  the  subject,  has 
further  pointed  out  that  during  pregnancy,  and  in  the  ]3arturient  state, 
they  are  apt  to  suffer  from  ulcerative  endocarditis  of  a  most  malignant 
character. 

Paroxysms  of  hysteria  and  attacks  of  chorea  are  not  infrequent, 
especially  the  former.  Chlorosis  is  also  a  large  and  important  element 
in  the  formation  of  exophthalmic  goitre,  but  the  cases  are  too  rare  to 
give  this  fact  importance  here.  The  duration  of  chlorosis  is  very  un- 
certain. It  is  not  a  self -limited  disease,  and  manifests  no  tendency  to 
spontaneous  cure.  It  may  terminate  in  recovery,  in  partial  recovery, 
or  in  some  intercurrent  malady,  as  pneumonia,  typhoid  fever,  endo- 
carditis, perforating  ulcer  of  the  stomach,  cerebral  haemorrhage,  etc. 
The  prognosis  is  favorable  for  simple,  uncomplicated  cases,  but  must 
be  guarded  for  cases  which  recur,  as  they  may  be  examples  of  chloro- 
sis with  vascular  changes. 

Treatment. — As  lessened  haematin  and  haemoglobulin  is  the  essen- 
tial element  in  chlorosis,  the  administration  of  iron  is  the  main  jjoint 
in  the  therapy.  The  combinations  of  iron  with  a  mineral  acid  (tincture 
of  the  chloride,  sulphate,  etc.)  are  usually  more  effective  than  the  so- 
called  mild  preparations.  The  addition  of  manganese  is  useful,  be- 
cause of  the  intimate  association  of  these  minerals  in  the  blood-glob- 


222  DISEASES  OF  THE  BLOOD-FORMING  ORGANS. 

ules.  The  utility  of  iron  does  not  consist  solely  in  supplying  to  the 
organism  of  the  chloritic  a  material  which  is  deficient,  but  in  stim- 
ulating the  appetite  and  the  digestion,  so  that  more  food  is  taken  and 
disposed  of  more  easily.  It  follows  that  iron  must  be  given  in  large 
doses  in  this  disease,  and  experience  is  in  harmony  with  theory  on  this 
point.  Excellent  results  are  obtained  from  the  conjoined  or  simul- 
taneous administration  of  iron  and  the  phosphates — notably  from  the 
pyrophosphate  of  iron  and  lactophosphate  of  lime.  Again,  many  cases 
do  better — the  majority,  within  my  observation — by  the  combination 
of  iron  with  some  agent  having  the  power  to  exalt  the  cerebro-spinal 
functions,  as  arsenic  and  strychnia.  An  excellent  prescription,  not- 
withstanding the  chemical  incompatibility,  is  the  pil.  ferri  carb.  with 
arsenious  acid  or  arseniate  of  iron  ;  or.  Fowler's  solution  may  be  given 
separately,  after  the  chalybeate.  Strychnia,  iron,  and  manganese  sul- 
phates can  be  given  in  pill-form.  Hammond,  influenced  by  his  theory 
of  the  nervous  origin  of  chlorosis,  holds  that  arsenic  is  the  true  rem- 
edy, and  his  experience  supports  his  theory.  The  author  has  seen  the 
best  results  from  a  combination  of  iron  and  arsenic,  and  this  fact  he 
urges  upon  the  attention  of  his  readers.  A  generous  diet,  out-door 
air,  and  moderate  exercise,  are  essential  elements  in  the  therapy  of 
chlorosis.  The  combined  treatment  of  rest,  forced  feeding,  massage, 
and  faradization,  advocated  by  Weir  Mitchell  in  these  cases,  seems  to 
succeed  in  many  wonderfully.  The  measures  above  recommended, 
combined  with  suitable  hygiene,  rarely  fail,  however,  to  effect  a 
prompt  cure.  No  treatment  will  accomplish  more  than  a  temporary 
cure  in  those  cases  associated  with  changes  or  abnormalities  in  the 
vascular  system  ;  for  the  chlorosis  will  recur  from  time  to  time,  and 
possibly  the  case  terminate  at  last  with  ulcerative  endocarditis  in  the 
pregnant  or  parturient  state. 


PROGRESSIVE    PERNICIOUS    AN2EMIA— ESSENTIAL    ANiEMIA— 
MALIGNANT   ANiEMIA. 

Definition. — By  the  term  progressive  pernicious  ancemia  is  meant 
a  form  of  anaemia  of  most  severe  character,  progressive  and  fatal,  and 
accompanied,  toward  the  termination,  by  a  fever. 

Causes. — This  disease  occurs  usually  in  women  from  fifteen  to 
forty  years,  who  have  been  repeatedly  pregnant  or  subjected  to  debili- 
tating influences,  as  uterine  haemorrhage,  or  to  bad  hygiene.  It  is 
not  known  why,  in  some  cases,  these  etiologic  factors  will  cause  anse- 
mia,  and,  in  a  few  rare  individuals,  excite  the  far  more  formidable, 
indeed  malignant,  ailment. 

Pathological  Anatomy. — There  is  little  or  no  emaciation  due  to  the 
disease.  There  may  be  a  good  deal  of  fat  under  the  skin,  and  the 
body  may  present  an  appearance  of  fullness  and  roundness,  due  to  a 


■ 


PERNICIOUS   ANJSMIA.  223 

general  oedema  ;  but  usually  the  oedema  is  about  the  ankles.  The 
skin  may  contain  petechia}  of  a  purplish  or  brownish  tint,  scattered 
over  the  trunk  and  limbs.  There  may  be  ecchymoses,  having  the  va- 
rious colors  characteristic  of  extravasated  blood  at  different  periods, 
and  vibices,  due  to  the  same  cause,  and  produced  by  pressure.  There 
is  more  or  less  serum  in  the  various  cavities,  and  the  organs  generally 
are  pale  and  bloodless.  The  changes  in  the  heart  and  arterial  system 
are  the  same  as  already  described  (see  Anemia),  and  consist  in  fatty 
degeneration  of  the  cardiac  muscles  (papillary)  and  of  the  intiraa  of 
the  aorta  and  principal  arteries.  The  alterations  in  the  composition 
of  the  blood  are  also  similar  to  those  of  anaemia,  but  they  are  more  ex- 
tensive and  profound.  The  volume  of  the  blood  is  lessened,  the  red 
corpuscles  are  fewer,  the  albuminates  of  the  blood  diminished,  and  the 
fibrin  is  deficient.  There  is  no  constant  disturbance  in  the  normal 
ratio  of  the  white  and  red  corpuscles,  although  cases  have  been  re- 
ported in  which  the  leucocytes  were  increased. 

Symptoms. — The  exact  beginning  of  pernicious  anaemia  usually 
passes  unnoticed  ;  an  unwonted  paleness,  a  sense  of  fatigue  on  the 
least  exertion,  hurried  breathing,  and  palpitation  of  the  heart,  at  length 
attract  attention.  This  may  be  entitled  the  chronic  form.  In  a  few 
cases,  happening  during  pregnancy,  the  onset  is  rather  sudden,  and 
extreme  pallor,  palpitation,  and  breathlessness  on  making  any  effort 
appear  within  a  short  period.  The  progress  is  comparatively  rapid  in 
both  forms  after  the  symptoms  are  fully  developed,  and  in  a  short 
time  the  weakness  is  such  that  the  j^atient  is  confined  to  bed,  is  unable 
to  rise,  and  faints  on  attempting  to  assume  the  erect  posture.  Various 
local  haemorrhages  take  place,  as  epistaxis,  bleeding  from  the  gums, 
menorrhagia,  extravasations  under  the  skin  and  into  the  retina.  The 
haemorrhages  into  the  retina  are  very  common,  and  consist,  on  oph- 
thalmoscopic examination,  of  small,  blackish,  brownish,  or  yellowish- 
brown  spots,  or  larger  patches  covering  more  or  less  of  the  fundus. 
They  may,  when  very  minute,  not  affect  the  vision,  although  present 
in  great  numbers  ;  but  an  extravasation  in  the  retina  of  considerable 
size  obscures  the  field  of  vision  correspondingly  (Immermann).  Small 
extravasations  or  larger  haemorrhages  may  take  place  in  the  brain, 
with  the  usual  results.  A  constant  symptom  is  fever,  but  it  does  not 
appear  until  near  the  end  of  the  case,  and  does  not  pursue  a  definite 
plan  or  type.  When  death  is  imminent,  the  fever  not  only  ceases,  but 
the  temperature  declines  below  normal,  falling  to  9.5°  Fahr.,  or  even 
lower. 

Course,  Duration,  and  Termination. — Although  pernicious  anaemia 
has  been  separated  from  allied  states,  yet  in  its  course  and  behavior 
it  strongly  resembles  anaemia  and  chlorosis,  especially  the  latter,  or 
more  closely  a  combination  of  the  two.  It  seems,  as  it  were,  anaemia 
added  to  chlorosis,  and  the  worst  features  of  each  fully  developed. 


22  i  DISEASES  OF   THE   BLOOD-FORMING   ORGANS. 

The  duration  is  not  self -limited,  and  hence  varies  greatly.  The  acute 
cases  usually  terminate  within  two  months,  but  the  more  chronic  ones 
continue  for  three  or  four  months.  The  mode  of  dying  is  by  exhaus- 
tion usually,  but  life  may  be  unexpectedly  terminated  by  sudden  pa- 
ralysis of  the  heart,  or  by  cerebral  hemorrhage. 

Diagnosis. — Pernicious  anaemia  is  distinguished  from  ansemia  and 
chlorosis  by  the  severity  of  the  symptoms  ;  from  albuminuria  by  the 
absence  of  albumen  from  the  urine  ;  from  leucocythemia  by  the  nor- 
mal condition  of  the  spleen,  liver,  and  lymphatics  ;  from  Addison's 
disease  by  the  absence  of  the  bronzing.  The  prognosis  is  highly  un- 
favorable, no  cases  of  cure  having  been  reported. 

Treatment. — There  is  no  specific  plan  of  treatment.  The  anaemic 
symptoms  require  iron  ;  but,  if  haemorrhages  are  occurring,  iron  must 
be  discontinued,  when  arsenic,  ergot,  and  quinia  may  be  substituted. 
A  generous  diet  and  stimulants  must  be  administered  from  the  begin- 
ning. Unfortunately,  thus  far  no  results  have  followed  the  treatment, 
and  the  cases  have  pursued  their  evil  course  until  the  end. 

THROMBOSIS  AND  EMBOLISM. 

Definition. — By  the  term  thrombus  is  meant  the  formation  of  a  clot 
in  a  blood-vessel — an  ante-mortem  coagulation.  The  mechanism  of 
its  formation  and  the  pathological  changes  associated  with  it  ave  called 
thrombosis.  A  detached  clot,  or  parts  of  a  clot,  or  any  new  formation 
circulating  in  the  blood-current,  is  designated  an  embolus,  in  the  jdIu- 
ral  emboli,  as  fibrin  embolus,  fat  embolus,  pigment  embolus,  etc.  The 
secondary  obstruction  and  the  changes  consequent  thereon,  produced 
by  an  embolus,  are  known  as  embolism — as  cerebral  embolism,  pulmo- 
nary embolism,  etc. 

Causes. — The  process  of  coagulation  of  the  blood  consists  in  the 
precipitation  and  consolidation  of  certain  of  its  constituents,  which, 
under  normal  conditions,  remain  fluid.  When  a  blood-clot  forms,  the 
fibrino-plastic  substance  acts  on  the  fibrinogenous,  the  former  contained 
in  the  blood  corpuscles,  the  latter  in  the  liquor  sanguinis.  This  forma- 
tion of  fibrin,  by  the  reaction  between  two  other  principles,  is  like  the 
production  of  prussic  acid  by  the  reaction  between  amygdalin  and  emul- 
sin,  or  of  the  volatile  oil  of  mustard,  by  myrosin  and  myronic  acid. 
The  formation  of  fibrin,  or  the  coagulation  of  the  blood,  only  takes 
place  in  the  vessels  when  there  occurs  a  slowing  of  the  current,  or 
when  there  is  a  change  in  the  parietes  of  the  vessels.  In  diseases 
characterized  by  abnormal  increase  of  the  fibrin  {hyperinosis),  should 
the  blood-current  be  much  reduced  in  rapidity  and  force,  coagulation 
will  take  place.  Thus  in  post-partum  haemorrhage,  a  thrombus  not  in- 
frequently forms  in  the  pulmonary  artery.  When  the  vis-a-tergo  is 
weak,  and  an  obstacle  is  placed  in  the  capillary  region  in  front,  tlirorabi 


THROMBOSIS   AND   EMBOLISM.  225 

may  form  in  the  veins  next  the  capillary  system — as,  for  example,  in 
the  pulmonary  veins,  in  chronic  interstitial  pneumonia  ;  in  the  renal 
veins,  in  parenchymatous  nephritis,  etc.  Again,  when  vessels  are 
divided,  haemorrhage  is  arrested  by  thrombi  which  close  the  divided 
extremity.  Thrombosis,  the  result  of  changes  in  the  tunics  of  the  ves- 
selsj  is  more  frequent  in  relation  to  disease  of  the  arteries  than  of  the 
veins.  Foi'merly  the  notion  was  entertained  that  phlebitis  played  an 
important  part  in  the  process  of  thrombosis  and  embolism  ;  that  the 
intima  was  the  seat  of  exudations  and  other  products  of  inflammation 
to  which  the  formation  of  a  clot  was  immediately  due,  but  it  is  now 
known  that  inflammation  of  veins  is  interstitial ;  that  the  tunica  intima, 
deprived  of  its  nutritive  materials,  undergoes  necrosis,  and  becomes  a 
foreign  body,  about  which  coagulation  of  blood  takes  place.  This, 
however,  is  a  comparatively  rare  cause  of  thrombus  formation,  as  this 
process  occurs  in  the  veins.  It  is  in  the  arterial  system  that  those 
changes  take  place  which  enter  so  largely  into  the  phenomena  of 
thrombosis  and  embolism — the  results  of  endocarditis  and  endarteritis. 
The  formation  of  vegetations  in  endocarditis,  especially  on  the  valves 
is  a  fruitful  source  of  embolisms.  In  endarteritis  slow  degenerative 
changes  occur  in  the  walls  of  the  vessels,  the  internal  layer  (intima) 
becomes  involved — thickened,  roughened,  necrotic — and  then  thrombi 
form.  Any  foreign  body,  as  a  needle  introduced  into  a  vessel,  will 
induce  coagulation  and  the  gradual  formation  of  an  obliterating 
thrombus.  An  embolus  is  formed  when  a  portion  of  a  thrombus,  de- 
tached from  the  parent  clot,  enters  the  blood-current.  The  density  of 
the  clot  and  its  position  are  important  elements  in  the  detachment  of 
emboli.  The  softer  the  clot  the  more  easily  it  is  broken  up,  and,  if 
situated  near  to  the  entrance  of  a  communicating  vein,  the  more  cer- 
tain a  portion  of  it  will  be  broken  off  from  the  main  mass.  The  coni- 
cal shape  which  the  thrombus  assumes,  jn-ojecting  beyond  the  point  of 
attachment  to  the  intima,  and  floating  freely  at  its  end,  are  physical 
conditions  favoring  its  separation.  Besides  the  action  of  these  forces, 
emboli  are  detached  by  coughing,  vomiting,  sudden  jars,  straining 
muscular  movements,  etc.  After  fractures  an  immense  number  of  fat 
emboli  may  enter  the  systemic  circulation,  and  now  and  then  a  phle- 
bolithe  is  a  cause  of  obstruction  ;  cancer  products  may  penetrate  the 
blood  and  be  distributed  widely  ;  multiple  embolisms  may  be  caused 
by  the  entrance,  from  a  depot  of  putrefactive  matters,  of  putrid  fer- 
ments ;  and  pigment  emboli  may  be  a  product  of  malarial  fevers. 

Pathological  Anatomy. — Recent  thrombi  consist  of  soft,  brownish- 
red  coagula,  either  in  the  form  of  a  plug  which  fills  the  vessel  and 
entirely  shuts  off  the  circulation,  or  in  a  plaque  or  tablet  attached  to 
one  side  of  the  vessel-wall,  permitting  still  a  part  of  the  blood  to  pass 
through.  In  the  case  of  the  lattei-,  successive  deposits  of  fibrin  pro- 
duce a  stratified  clot,  which  may  ultimately  obstruct  the  vessel.  When 
15 


226  DISEASES   OF  THE   BLOOD-FORMING   ORGANS. 

a  vessel  is  ligated,  tlie  clot  formed  does  not  extend  beyond  the  first 
communicating  vessel,  but,  when  the  thrombus  is  spontaneous,  the 
coagulum  may  increase  by  successive  deposition  of  material  until  it 
extends  into  a  neighboring  vessel.  If  a  thrombus  is  suddenly  formed, 
there  will  be  a  uniform  distribution  of  the  red  and  white  globules 
throughout  the  coagulum  ;  if  slowly  formed,  the  mass  will  have  a 
stratified  arrangement,  due  to  the  adhesion  of  the  white  corpuscles  to 
each  other,  and  their  accumulation  along  the  walls  of  the  vessel,  and 
on  the  surface  of  the  clot,  so  that,  when  a  section  is  made  of  a  throm- 
bus formed  by  successive  deposition,  it  will  be  found  to  be  made  up 
by  alternating  layers  of  ordinary  blood-clot  and  of  white  corpuscles. 
Thrombi  are,  therefore,  of  two  kinds,  stratified  and  unstratified.  The 
first  steps  in  the  organization  of  a  thrombus  consist  in  a  process  of  con- 
densation :  the  liquid  disappears,  the  red  globules  lose  their  color,  and 
the  mass  contracts  an  intimate  adhesion  to  the  intima  of  the  vessel. 
Vessels  are  formed  by  the  union  and  canalization  of  migrated  white 
corpuscles  (Rindfleisch),  and  the  remainder  of  the  thrombus  consists 
of  a  fine  reticulation  of  fibers  and  corpuscles,  but  the  corjjuscles  have 
usually  disappeared  at  the  expiration  of  two  months.  Softening  of 
the  clot  begins  in  the  oldest  part.  There  is  no  attempt  at  organiza- 
tion, and  the  delicate  reticulation  of  fibrin  breaks  up  into  a  uniform 
granular  mass.  The  red  globules  lose  their  coloring  matter,  and,  mixed 
with  the  other  contents  of  the  thrombus,  form  a  white  or  yellowish- 
white  fluid  having  the  consistence  of  cream,  and  an  appearance  like 
"laudable  pus,"  but  differing  from  pus  in  structure,  for  on  microscopic 
examination  it  is  seen  to  be  composed  of  albuminous  particles,  fat- 
molecules,  and  altered  blood-globules.  While  the  interior  of  the 
thrombus  presents  this  puriform  appearance,  the  exterior  may  have 
the  brownish-red  of  the  clot,  and  there  may  be  various  shades  of  color, 
representing  various  stages  in  the  process  of  softening.  When  the 
process  is  complete  there  remains  a  puriform-like  collection,  in  which 
no  red  globules  remain  undestroyed,  and  together  with  the  white  are 
transformed  finally  into  fat-gi*anules.  An  embolus  derived  from  a 
thrombus  will  have  the  appearance  belonging  to  the  age  and  condition 
of  the  latter.  The  vessel  in  which  it  is  lodged  will  be  damaged  at  the 
point  of  lodgment,  but  in  front  and  behind  the  embolus,  will  be  healthy. 
The  vessel  may  be  completely  or  only  partially  obstructed.  If  com- 
pletely, coagulation  will  ensue  behind  the  point  of  obstruction  fonning 
a  thrombus  ;  if  partially,  successive  depositions  of  coagulum  will  occur, 
and  a  thrombus  will  form  about  the  embolus.  The  bifurcation  of 
arteries  is  the  usual  point  at  which  an  embolus  lodges.  Its  effects  are 
not  limited  to  the  point  of  lodgment,  but  include  the  whole  area  nour- 
ished by  the  vessel,  and  the  wider  zone  supplied  by  the  branches  re- 
maining permeable.  The  part  receiving  blood  through  the  obstructed 
vessel  at  once  becomes  ansemic  ;  but  the  neighboring  district  is  the 


THROMBOSIS  AND   EMBOLISM.  227 

_  seat  of  an  active  hypersemia,  which  is  designated  collateral  hypercBmia. 
One  result  of  the  increased  pressure  in  this  hyperaemic  area  is  the  rup- 
ture of  small  or  large  vessels  and  extravasation  of  blood.  If  the  ves- 
sel obstructed  is  small  and  not  a  terminal  artery,  the  anastomoses  may 
be  sufficient  to  supply  the  anoemic  district.  If,  however,  the  compen- 
satory circulation  is  insufficient  or  absent,  the  ischaemic  part  dies — un- 
dergoes necrobiosis,  gangrene,  or  necrosis.  The  consequences  follow- 
ing arrest  of  the  circulation  by  an  embolus  depend  largely  on  the 
position,  still  more  on  the  size,  of  the  obstructed  vessel.  Dry  gangrene 
is  produced  by  embolic  blocking  of  a  vessel  of  an  extremity.  In 
internal  organs,  especially  the  brain,  centers  of  softening  and  fatty 
transformation  of  the  tissue  elements,  and  hgemorrhagic  extravasations 
in  the  area  of  collateral  hyperoemia,  are  results  of  embolism.  Besides 
the  haemorrhagic  extravasations,  infarctions  occur  in  the  parenchyma 
of  those  organs  supplied  with  Cohnheim's  terminal  arteries.* 

Symptoms. — The  position  of  a  thrombus  or  an  embolus  exercises  a 
most  important  influence  on  the  symptoms  caused  by  them.  When  a 
thrombus  occupies  a  vein  of  an  extremity,  oedema  of  all  the  parts  be- 
low is  a  result,  and,  if  the  obstructed  vein  is  adjacent  to  important 
nerves,  excessive  pain,  or  troubles  of  motility,  will  also  be  present  by 
reason  of  the  pressure  of  the  distended  vessel.  Gangrene  is  not  a 
result,  since  the  nutrition  of  the  parts  is  accomplished,  although  feebly 
and  impei'fectly,  but  moist  gangrene  may  be  produced  if  other  injuries 
are  superadded — as  erysipelas,  traumatism,  compression,  etc.  A  cure 
in  such  a  case  is  in  part  effected  by  the  collateral  circulation,  but  in  a 
truer  sense  by  the  canalization  of  the  thrombus.  Notwithstanding  the 
similarity  in  the  symptoms,  caused  by  thrombosis  and  embolism  re- 
spectively, there  is  a  great  difference  in  the  time  at  which  the  phe- 
nomena manifest  themselves  :  the  symptoms  of  autochthonous  throm- 
bosis come  on  gradually  ;  of  embolism  suddenly,  with  shock  (Wagner). 
Two  classes  of  symptoms  arise — affections  of  nutrition,  from  the  sim- 
plest disorder  up  to  gangrene,  and  functional  disturbances,  proper  to 
the  organ  affected.  These  symptoms  are  not  ascertained  with  the 
same  facility  in  all  situations.  In  the  extremities,  every  step  in  the 
local  process  is  easily  followed  and  interpreted,  but  in  internal  embo- 
lisms only  those  symptoms  due  to  perversion  or  suspension  of  fimction 
are  recognizable.  Embolic  obstruction  of  a  member  is  announced  by 
a  sudden  and  often  intense  pain  and  a  chill,  with  numbness,  loss  or 
diminution  of  tactile  sense,  coldness,  pallor  of  the  skin,  and  a  feeling 
of  deadness  and  weight,  and  paralysis  of  the  muscles  ;  the  pulsations 
wanting  below,  while  above  the  obstruction  they  are  full  and  strong. 
If  embolic  blocking  of  a  vein  in  the  brain,  there  occur  defects  of  speech, 
hemiplegia,  etc.  ;  if  of  a  pulmonary  artery,  sudden  difficulty  of  breath- 

*  Wagner,  op.  cit.    "  Untersuchungen  iiber  die  embolischen  Processe,"  von  Dr.  Julius 
Cohnheim,  Hirschwald,  pp.  112.     Berlin,  1872. 


228  DISEASES   OF  TEE   HEART. 

ing  and  sense  of  oppression,  with,  it  may  be,  intense  oppression  and 
anxiety  and  death.  Sudden  attacks  of  amaurosis  in  puerperal  fever, 
acute  rheumatism,  and  pyaemia,  are  usually,  due  to  embolism  of  the 
central  artery  of  the  retina.  Those  organs  not  well  supplied  with 
nerves,  as  the  liver,  kidneys,  and  mucous  membranes,  do  not  offer  dis- 
tinct reactions  on  embolic  blocking  of  their  vessels,  and  hence  the 
symptoms  are  obscure.*  If  the  immediate  danger  of  an  embolic  ob- 
struction is  past,  even  if  the  symptoms  are  very  formidable,  provided 
terminal  arteries  are  not  obstructed,  they  may  disappear  in  some  hours 
or  days  by  establishing  a  collateral  circulation. 

Treatment. — As  all  the  symptoms  are  due  to  the  obstruction  of 
vessels  by  a  blood-clot,  the  point  in  the  treatment  of  special  importance 
is  to  effect  a  solution  of  this  obstructing  material.  Theoretically, 
ammonia  possesses  a  solvent  power,  and  in  its  use  the  author  has  had 
most  striking  results  in  the  case  of  thromboses  and  embolisms  of  the 
brain.  To  accomplish  the  purj^ose  in  view,  ten  grains  of  the  carbonate 
of  ammonia  may  be  administered  in  a  tablespoonful  of  solution  of  the 
acetate,  three  or  four  times  each  day.  As,  however,  the  action  must 
be  slow,  the  point  of  contact  being  small,  the  remedy  must  be  very 
persistently  employed.  The  iodide  of  ammonium  may  be  administered 
in  a  solution  with  the  carbonate  also,  and  usually  with  good  results. 
Other  alkalies  possess  the  same  power,  but  to  a  less  extent.  The  most 
generally  useful  is  the  phosphate  of  soda,  in  drachm-doses,  three  times 
a  day,  used  for  many  weeks.  As,  however,  prompt  and  speedy  action 
is  needed  to  avoid  the  serious  structural  alterations  which  occur  so 
quickly,  the  ammonia  preparations  are  preferable  to  any  other  having 
the  same  effects. 


DISEASES  OF  THE  HEART. 


INFLAMMATION  OF   THE   PERICARDIUM— PERICARDITIS. 

Definition. — The  term  pericarditis  means  an  inflammation  of  the 
pericardium.  The  inflammation  may  be  limited  to  the  parietal  or 
visceral  layer,  or  to  a  part  of  either,  or  it  may  involve  the  whole  of 
both  surfaces.  In  the  former  case,  it  is  partial  or  circumscribed ;  in 
the  latter,  general  or  diffused.  The  inflammation  may  also  be  either 
acute  or  chronic. 

*  Ulile  and  Wagner,  op.  cit. 


PERICARDITIS.  229 

Causes. — Idiopathic  or  primary  pericarditis  may  arise  from  trau- 
matism or  from  cold.  In  those  cases  supposed  to  be  produced  by 
changes  of  temperature  there  is  usually,  probably,  a  diathetic  condi- 
tion— as  albuminuria — which  escapes  notice.  Secondary  pericarditis 
is  moi'e  common,  and  is  due  to  two  causes  :  to  an  extension  of  inflam- 
mation from  neighboring  parts — pneumonia,  left  pleurisy,  pulmonary 
tuberculosis,  caries  of  the  sternum  or  ribs,  aneurism  of  the  aorta,  endo- 
carditis, etc.  ;  to  the  rheumatic  dyscrasia.  The  dependence  of  peri- 
carditis on  rheumatism  has  been  very  differently  stated  by  the  different 
authorities.  That  in  about  one  third  of  all  the  cases  this  complication 
arises  is  the  opinion  of  Bamberger,  and  is  doubtless  a  close  approxi- 
mation to  the  truth,  but  Thompson  *  says  sixteen  per  cent.  The 
severity  of  the  cases,  but  not  the  position  of  the  joints  affected,  has 
some  influence  in  determining  the  frequency  of  the  complication.  The 
first  attack  is  more  liable  to  this  complication  ;  the  second  attack  stands 
next.  In  Thompson's  forty-three  cases  of  pericarditis,  twenty-five 
happened  during  the  first  attack  and  thirteen  during  the  second.  The 
author  has  seen  three  cases  in  which  the  pericarditis  preceded  the  joint 
affection.  Usually  this  complication  arises  during  the  period  of  great- 
est severity  of  the  disease — during  the  second  week,  the  favorite  days 
being  the  ninth  and  tenth  (Thompson).  Pericarditis  also  occurs  dur- 
ing the  course  of  certain  eruptive  fevers,  as  scarlatina,  variola,  in  puer- 
peral fever,  in  albuminui'ia,  scorbutus,  etc.,  but  there  are  no  numeri- 
cal data  for  an  exact  statement  of  the  relative  frequency.  As  regards 
the  period  of  life  in  which  pericarditis  happens,  there  are  differences 
in  the  two  sexes — women  being  more  liable  during  the  period  of  pu- 
berty, thirteen  to  twenty,  and  men  from  twenty  to  thirty,  the  average 
being  respectively  nineteen  and  twenty-five  (Thompson),  Men  are 
somewhat  more  liable  to  the  disease  than  women,  but  the  difference 
is  slight. 

Pathological  Anatomy. — In  the  first  stage  of  the  inflammation  there 
are  two  pathological  conditions  present :  an  alteration  of  the  tissue,  the 
seat  of  the  inflammation  ;  and  an  effusion  into  the  pericardial  sac. 
The  inflamed  membrane  is  marked  by  an  arborescence  of  minute  ves- 
sels, or  is  of  a  deep-red  color,  in  consequence  of  the  general  stasis^ 
and  contains  here  and  there  spots  of  extravasation  from  rupture  of 
over-distended  vessels.  The  membrane  becomes  dull,  cloudy,  and  at 
first  dry,  and  also  swells  from  interstitial  exudation,  and  its  resistance 
is  diminished  by  the  separation  of  the  connective-tissue  elements.  The 
stage  of  hypersemia  and  suspended  secretion  is  of  short  duration — ^last- 
ing from  a  few  hours  to  twenty-four,  the  shorter  rather  than  the  longer 
period.  Rarely  a  case  occurs  in  which  there  is  no  other  than  the  in- 
terstitial exudation,  no  moist  exudation  on  the  surface,  nor  effusion 

*  "  St.  George's  Hospital  Reports,"  vol.  iv,  p.  31. 


230  DISEASES   OF  THE  HEART. 

into  the  cavity.  Usually,  after  a  variable  period  of  a  few  hours,  the 
membrane  which  was  dry  becomes  coated,  especially  the  visceral  layer 
about  the  origin  of  the  great  vessels,  with  an  exudation  of  fibrinous 
substance,  having,  it  may  be,  a  thin,  pellicular  character,  or  thicker 
and  more  consistent,  but  soon  extending  over  both  surfaces.  Some- 
times the  exudation  is  reticulated,  sometimes  it  forms  conical  or  fili- 
form projections — pineapple  heart,  cor  villosum,  cor  tomentosum,  etc. 
These  peculiar  appearances  are  due  largely  to  the  movements  of  the 
heart  and  the  friction  of  the  exudation  on  the  two  surfaces.  When 
the  exudation  is  sero-fibrinous,  more  or  less  straw-colored  serum,  having 
flocculi  of  lymph  or  masses  of  fibrinous  substance  fl.oating  in  it,  is  con- 
tained in  the  cavity.  Instead  of  being  straw-colored  the  fluid  may 
retain  so  much  of  the  solid  exudation  churned  up  with  it  as  to  have  a 
creamy  consistence  and  a  yellowish  color  ;  or  it  may  have  a  reddish 
tint  from  a  slight  admixture  of  blood,  or  be  composed  largely  of  blood 
(hsemorrhagic  pericarditis).  The  serous  fluid  may  also  have  a  yellow- 
ish tint  from  the  presence  of  leucocytes,  or  the  exudation  may  have 
from  the  beginning  a  purulent  character.  The  latter  is  the  case  in 
pericarditis  occurring  during  pyaemia,  puerperal  septicpemia,  variola, 
etc.  The  IiEemorrhagic  exudation  occurs  in  chronic  alcoholismus  and 
in  scorbutus.  There  are,  therefore,  sero-fibrinous,  hgemorrhagic,  sero- 
purulent,  and  purulent  exudations.  A  strictly  serous  exudation  is 
found  in  general  dropsy,  in  dropsy  of  the  pericardium,  etc.,  but  not  in 
true  pericarditis. 

Effusions  may  be  entirely  removed,  even  those  consisting  largely 
of  solid  exudation.  The  fibrinous  matter  breaks  up  into  a  granular 
mass,  w^hich  gradually  becomes  fatty  ;  the  cells  also  undergo  a  fatty 
metamorphosis  ;  the  watery  part  is  quickly  taken  up  and  the  fatty 
emulsion  undergoes  slow  absorption.  A  complete  restoration  of  the 
parts  to  the  normal  may  ultimately  take  place,  but  this  is  an  excep- 
tional result.  It  is  to  be  expected  only  when  the  exudation  is  largely 
serous,  or  when  the  fibrinous  substance  is  dej)osited  on  a  small  extent 
of  surface  and  is  thin.  Usually  the  watery  part  of  the  exudation  is 
taken  up  ;  the  migrated  white-blood  corpuscles  in  the  mass  of  fibrin- 
ous exudation  assume  a  fusiform  shape,  unite  end  by  end,  and  form 
canals  or  blood-vessels,  and  thus  an  exudation  becomes  organized.  The 
epithelium  takes  part  in  these  changes,  by  the  proliferation  of  its 
cells,  and  the  mass  of  solid  exudation  is  composed  not  only  of  fibrinous 
substance,  but  migrated  leucocytes,  and  proliferating  epithelium, 
mixed  with  a  basis  substance,  composed  of  germinal  matter.*  Pro- 
jecting masses  of  exudation,  uniting  from  the  two  sides,  form  bands, 
which  organize  by  the  formation  of  vessels,  and  remain  j)ermanently. 
There  may  be  a  thin  band  or  bands  connecting  the  visceral  and  pa- 
rietal layers,  or  larger  and  broader  bands  which,  uniting,  form  sub- 
*  Rindfleiscb,  op.  r.it.,  p.  265. 


PERICARDITIS.  231 

divisions  of  the  sac,  or,  the  two  surfaces  may  be  glued  together,  en- 
tirely obliterating  the  cavity  of  the  pericardium.  The  union  may  be 
so  perfect  that  the  most  careful  dissection  can  not  separate  them. 
Calcareous  deposits  may  subsequently  form  in  the  exudation,  or  the 
whole  of  it  may  finally  become  so  completely  calcified,  by  the  deposit 
of  lime  salts,  that  the  heart  is  inclosed  in  an  apparently  bony  case. 
The  adherent  pericardium  is  not  unfrequently  reported  in  medical 
journal  literature  as  a  congenital  absence  of  this  sac,  and  the  calcifica- 
tion of  an  exudation,  as  the  formation  of  a  true  bony  envelope  of  the 
heart.  The  fluid  exudation  may  persist  notwithstanding  the  forma- 
tion of  neo-membrane  and  bands  of  adhesion,  and  it  changes  in  quan- 
tity, now  increasing  while  fresh  deposits  of  fibrinous  substance  is 
occurring,  now  diminishing  with  a  temporary  amendment ;  some- 
times assuming  a  hemorrhagic  character,  but  more  frequently  becom- 
ing purulent.  The  more  solid  and  unorganized  exudation,  crossed 
here  and  there  by  bands  of  adhesion,  assumes  a  grayish  color,  and 
undergoes  ultimately  a  caseous  transformation. 

The  muscular  tissue  of  the  heart  becomes  diseased  by  reason  of 
the  proximity  of  the  inflammation — an  acute  myocarditis — which 
affects  the  muscular  tissue  in  contact  with  the  inflamed  membrane. 
The  muscular  fibers  become  paler  than  normal,  soften,  and  are  infil- 
trated with  fat-granules,  so  that  the  muscular  contractility  is  impaired, 
and  hence,  if  the  lesion  extends,  the  power  of  the  heart  will  be  greatly 
lessened.  The  extent  of  the  pericarditis  and  the  duration  of  the  in- 
flammation have  a  material  influence  on  the  extent  of  the  myocarditis. 
In  hsemorrhagic  and  purulent  exudations,  the  damage  to  the  heart  is 
greater.  The  strain  on  the  heart  due  to  the  increased  exertion  re- 
quired in  fever,  and  the  compression  of  the  exudation,  interfering  with 
the  passage  of  the  blood  to  the  muscular  tissue  of  the  heart,  also  affect 
the  nutrition  of  the  organ,  and  favor  degenerative  changes.  Endo- 
carditis may  result  by  an  extension  of  disease  from  the  inflamed 
pericardium,  as  has  been  experimentally  and  clinically  established. 
In  chronic  pericarditis  the  myocarditis  persists,  the  walls  yield  to  the 
blood-pressure,  and  the  cavities,  the  right  especially,  dilate. 

Symptoms. — When  an  idiopathic  pericarditis  comes  on,  the  initial 
symptoms  occurring  are  those  of  any  acute  serous  inflammation : 
malaise,  chill,  fever,  increased  respiration,  loss  of  appetite,  frequently 
nausea  and  vomiting.  Pain  of  a  dull,  heavy  character,  or  a  feeling  of 
soreness,  is  felt  in  the  chest,  but  not  invariably.  Acute  pain  in  the 
position  of  the  pericardium  is  experienced  only  in  those  cases  with 
pleuritis  of  the  adjacent  portion  of  the  pleura,  so  that  the  real  signifi- 
cance of  any  soreness  or  pain  felt  is  ascertainable  only  on  physi- 
cal exploration.  When  pericarditis  is  secondary  to  an  existing  dis- 
ease, there  are  no  marked  disturbances  to  indicate  its  onset — no  dis- 
tinctive increase  in  the  temperature  and  pulse-rate,  or  in  the  respiratory 


232  DISEASES   OF   THE  HEART. 

movements,  but  there  may  be  some  praecordial  anxiety  and  oppres- 
sion, so  that,  in  all  cases  of  diseases  in  which  inflammation  of  the  peri- 
cardium is  liable  to  occur,  systematic  physical  exploration  of  the 
chest  should  always  be  practiced. 

The  fever  movement  in  simple  idiopathic  pericarditis  is  of  the  remit- 
tent type,  but  in  the  secondary  disease  it  does  not  modify  that  of  the 
existing  malady.  The  state  of  the  circulation  varies  from  a  condition 
of  high  tension,  with  full,  strong  pulse,  to  great  feebleness,  low  ten- 
sion, and  small,  irregular,  and  unequal  pulse.  A  weak,  irregular  pulse 
is  characteristic  only  of  cases  with  considerable  effusion,  with  myo- 
carditis, or  exhausted  by  the  severity  and  duration  of  this  disease.  The 
rational  signs  of  pericarditis  possess  but  little  value  ;  but  the  physical 
signs  are  highly  significant.  In  the  young,  a  small  amount  of  effu- 
sion may  render  the  precordial  space  prominent,  but,  in  adults,  only 
a  large  accumulation  will  push  out  the  intercostal  spaces  sufficiently 
to  produce  bulging,  unless  the  lung  is  shrunken,  or  there  are  pleuritic 
adhesions  so  situated  as  to  prevent  the  outward  expansion  of  the  peri- 
cardium. When  there  is  any  considerable  distention  of  the  sac  and 
anterior  bulging,  the  nipple  of  the  left  side  is  thrown  up  higher 
than  its  fellow  of  the  opposite  side.  In  consequence  of  the  effusion, 
the  sac  of  the  pericardium  is  enlarged,  and  the  mobility  of  the  heart 
on  changes  of  position  is  increased.  Hence,  on  jDalpation,  this  in- 
creased mobility  is  ascertained  by  the  different  positions  in  which  the 
apex-beat  can  be  felt.  "When  the  effusion  is  suflficient  to  force  the 
heart  to  a  more  horizontal  position,  the  apical  impulse  is  farther  out 
and  upward.  As  the  effusion  increases,  filling  the  sac,  the  apical  im- 
pulse becomes  weaker  and  weaker,  and  is  finally  no  longer  felt,  as  the 
fluid  is  interposed  between  the  apex-beat  and  the  chest-wall.  When 
the  systole  of  the  heart  is  weakened  by  myocarditis,  or  exhaustion, 
the  apical  impulse  disaj^pears  earlier,  especially  if  there  be  interposed 
a  thick  layer  of  soft  exudation  ;  on  the  other  hand,  the  apex-beat  will 
be  felt  longer  when  there  is  hypertrophy  of  the  heart,  and  may  not 
disappear  at  all  if  old  adhesions  keep  the  apex  against  the  chest-wall. 
A  change  of  position,  as  bending  the  body  forward,  may  cause  the 
apical  impulse  to  be  felt  again  when  it  had  disappeared  on  the  dorsal 
decubitus.  On  palpation,  for  a  brief  period  may  occasionally  be  felt  a 
vibration  of  the  chest-wall,  due  to  the  rubbing  of  the  roughened  sur- 
faces together.  To  develop  this  sensation,  firm  pressure  must  be  made 
in  the  intercostal  space  with  the  finger-tips.  It  is  exceedingly  rare  for 
this  friction  fremitus  to  be  stronsf  enou2:h  to  excite  vibrations  of  the 
chest-wall,  which  may  be  perceived  by  the  hand  laid  on  the  prrecordial 
space.  It  is  a  rough,  jarring,  rasping  sensation,  similar  to  but  quite 
distinct  from  the  frei/u'ssement  cataire,  or  purring  tremor,  and  is  not 
exactly  isochronous  with  the  cardiac  systole  and  diastole,  although  a 
to-and-fro  movement. 


PERICARDITIS. 


233 


The  area  of  cardiac  dullness  is  increased  Avhen  the  effusion  is  suf- 
ficient in  amount.  The  enlargement  of  the  area  of  relative  dullness  is 
more  important  in  a  diagnostic  point  of  view,  because  there  may  be 
no  change  in  the  absolute  dullness,  even  when  there  is  considerable 
effusion.  The  diminished  sonoriety  is  first  perceived  at  the  sternal 
end  of  the  third  and  fourth  ribs — at  the  base  of  the  heart.     The  dull 


Fig.  16. — Effusion  into  the  Sac  of  the  Pericardium. 


space  has  a  triangular  form,  with  its  apex  uppermost  and  base  down- 
ward— the  right  line  of  the  triangle  extending  from  the  apex  at  the 
second  rib  and  sternum,  along  the  right  border  of  the  sternum,  and 
even  beyond,  to  the  right  sixth  and  seventh  ribs  and  sternum  ;  the 
base-line  of  the  triangle  passing  through  the  seventh  intercostal  to 
the  axillary  border,  and  there  intersecting  the  left  line.  When  the 
effusion  is  extreme,  the  epigastrium  is  pushed  outward  by  the  descent 
of  the  diaphragm  and  the  left  lobe  of  the  liver.-  The  size  of  the  trian- 
gular space  is  enlarged  by  sitting  up  and  by  bending  forward.  When 
the  apex-beat  can  still  be  felt,  and  the  area  of  dullness  extends  beyond 
it,  this  fact  indicates  that  the  sac  of  the  pericardium  is  greatly  dis- 
tended, and  consequently  forced  beyond  the  apex,  and  is  therefore  an 
important  sign  of  effusion.  A  change  in  the  position  of  the  dullness 
may  be  slightly  effected  by  changing  the  decubitus  of  the  patient,  the 
fluid  obeying  the  laws  of  gravity.  The  pressure  of  the  lung  in  the 
neighborhood  of  the  pericardium  is  a  necessary  result  of  the  accumu- 
lation of  fluid  ;  but  this  condensation  is  distinguished  from  effusion 


234  Diseases  of  the  heart. 

by  the  vocal  fremitus,  which  is  weakened  or  absent  in  the  latter,  but 
increased  or  normal  in  the  former.  In  estimating  the  results  of  per- 
cussion, two  sources  of  error  may  interfere  :  the  dullness  may  be  more 
extensive  than  the  amount  of  the  effusion  warrants  ;  it  may  be  less. 
The  first  is  due  to  adhesions  which  have  the  effect  to  retract  the  lung 
from  the  pericardium,  and  to  push  the  heart  forward,  thus  enlarging 
unduly  the  area  of  absolute  dullness  ;  in  the  other,  the  lung  is  attached 
anteriorly,  and  the  heart  lies  deeply,  and  is  still  further  depressed  by 
the  weight  of  the  effusion.  The  pericardial  friction  murmur  is  the 
most  significant  of  the  physical  signs  of  pericarditis,  and  is  produced 
by  the  rubbing  together  of  the  two  surfaces  roughened  by  exudations, 
or  by  one  roughened  surface.  This  hruit  makes  the  impression  on  the 
ear  of  scraping,  grating,  creaking,  churning,  and  various  modifications 
of  these  noises.  They  are,  ordinarily,  resolvable  into  three  :  the 
creaking  of  new  leather,  grating,  or  scraping.  The  sound  may  be 
partial  or  general ;  it  corresponds  to  the  seat  of  the  exudation,  and  is 
not  confined  to  the  situation  of  the  orifices  of  the  heart,  but  is  heard 
with  the  maximum  intensity  at  the  third  intercostal  space  on  both 
sides  of  the  sternum.  The  area  over  which  it  is  audible  depends  on 
the  extent  of  the  exudation.  The  hruit  accompanies  the  heart-sounds, 
but  is  not  confined  to  them,  and  extends  into  the  interval,  and  may 
indeed  occupy  the  whole  revolution  of  the  cardiac  movement.  Hence 
the  term  '■^  hruit  de  galops  Usually  or  frequently,  the  hruit  is  pre- 
systolic, systolic,  and  diastolic — the  presystolic  corresponding  to  the 
auricular  systole,  and  the  others  to  the  systole  and  diastole  of  the  ven- 
tricles. When  there  is  no  effusion  (dry  pericarditis),  there  will  be 
usually  no  rational  symptoms  of  the  malady — nothing  but  fever,  and 
the  physical  signs  of  pericardial  inflammation. 

The  friction  murmur,  as  well  as  the  friction  fremitus,  occur  early, 
and  are  recognized,  if  at  all,  within  the  first  two  days,  and  they  persist 
for  several  days  or  weeks,  according  to  the  progress  and  amount  of 
the  effusion.  They  may  decline  in  two  or  three  days  and  disappear, 
as  the  effusion  fills  the  sac  and  separates  the  two  surfaces,  so  that  fric- 
tion is  no  longer  possible.  If  the  effusion  is  absorbed,  then  the  hruit 
will  become  audible  again.  When  the  silence  of  the  hruit  is  due 
to  adhesions,  there  will  be  no  return  of  it  when  it  ceases.  With 
the  increase  of  the  effusion  the  heart  -  sounds  become  weaker,  and 
finally  are  no  longer  heard  in  some  cases  ;  but  usually  they  continue 
to  be  audible,  although  very  feebly.  The  character  of  the  pulse,  dur- 
ing pericarditis,  has  no  special  quality  ;  it  may  be  but  slightly  elevated 
above  the  normal  ;  it  may  be  very  much  accelerated  ;  its  rhythm  may 
be  much  altered.  At  the  onset  of  the  inflammation,  the  pulse  may  be 
strong,  the  tension  high  ;  but  this  is  not  maintained,  the  pulse  becom- 
ing weak,  and  the  arterial  tension  low  from  depression  of  the  vital 
powers  and  the  occurrence  of  myocarditis.     A  large  effusion  exerts  a 


PERICARDITIS.  235 

mechanical  pressure  upon  the  great  vessels  within  the  pericardial  sac 
— the  aorta  and  pulmonaiy  artery — and  interferes  with  their  proper 
filling.  Also,  as  the  veins  can  not  empty  their  blood  into  the  auricles 
fully,  they  are  kept  over-distended,  and  an  abnormal  fullness  of  the 
venous  system  in  general  is  the  result.  Stasis  of  the  venous  system 
causes  passive  congestion  of  the  lungs,  bronchial  catarrh,  difficult 
breathing,  cyanosis,  and  oedema.  The  venous  congestion  occurs  in  the 
brain,  and  is  manifested  objectively  by  headache,  vertigo,  epistaxis, 
etc.  ;  in  the  liver,  causing  enlargement  of  the  organ  and  hypera^mia  of 
the  portal  system  ;  and  in  the  kidneys,  inducing  albuminuria.  Irrita- 
tion of  the  phrenic  excites  a  most  distressing  hiccough.  Difficulty  of 
breathing,  cyanosis,  feebleness  of  the  heart's  action,  are  also  produced 
by  myocarditis,  which  is  really  an  acute  fatty  degeneration.  The 
heart's  movements  are  not  only  feeble,  but  scarcely  distinguishable  ; 
the  pulse  irregular,  intermittent,  feeble  ;  the  sounds  of  the  heart  are 
hardly  recognizable,  and  the  first  sound  is  often  absent ;  the  tempera- 
ture falls,  the  legs  become  oedematous,  and  death  soon  closes  the 
scene.  "When  severe  dyspnoea  and  cyanosis  come  on  in  the  course  of 
pericarditis,  they  are  more  frequently  due  to  the  damage  done  to  the 
heart's  muscle  than  to  the  mechanical  effects  of  the  effusion.  Again, 
the  same  symptoms,  in  a  less  extreme  degree,  however,  may  be  due  to 
nervous  disturbance — to  irritation  of  the  pneumogastric  and  phrenic. 
Dysphagia  may  be  caused  by  pressure  of  the  effusion  on  the  oesopha- 
gus, and  aphonia  by  pressure  on  the  recurrent  laryngeal  nerve. 

Course,  Duration,  and  Termination. — The  course  of  pericarditis  is 
not  always  upon  a  uniform  plan,  and  there  are  peculiarities  due  to 
the  causes  and  complications.  Those  cases  arising  in  the  course  of 
puerperal  septicsemia,  scorbutus,  or  pyaemia,  are  shorter  in  duration, 
and  greatly  more  fatal  than  those  which  are  due  to  the  rheumatic  di- 
athesis. The  duration  is  influenced  by  many  circumstances.  In  sim- 
ple, uncomplicated  cases,  terminating  in  health,  the  effusion  may  be 
absorbed  and  recovery  take  place  in  from  ten  days  to  two  weeks. 
When  a  case  tends  to  recover,  the  severe  symptoms  subside,  the  fever 
and  the  difficulty  of  breathing  cease,  the  appetite  returns,  and  conva- 
lescence is  established.  When  there  is  much  effusion,  and  yet  the  ten- 
dency is  toward  health,  the  area  of  dullness  lessens,  the  apical  impulse 
returns,  the  friction  murmur  and  fremitus  reajDpear  for  a  short  period, 
the  normal  sounds  are  heard  again,  and,  with  these  evidences  of  im- 
pi'ovement  afforded  by  the  physical  signs,  are  also  the  rational  symp- 
toms of  cessation  of  dyspnoea,  of  fever,  and  return  of  appetite.  In 
other  cases  the  improvement  is  partial ;  the  rational  and  physical  signs 
of  pericarditis  persist,  and  the  subsequent  history  is  that  of  chronic 
cardiac  troubles.  In  other  cases  a  fatal  termination  takes  place  early 
— in  the  scorbutic  form  with  haemorrhage  in  a  few  hours  after  the  well- 
defined  symptoms  come  on  ;  in  cases  with   large  effusion,  dyspnoea 


236  DISEASES   OF  THE   HEART. 

delirium,  etc.,  death  will  occur  in  a  week  or  ten  days  ;  in  cases  with 
myocarditis  and  syncopal  attacks,  according  to  the  age  and  other  cir- 
cumstances, a  fatal  termination  may  occur  within  the  first  two  weeks. 
According  to  Thompson,  the  average  duration  of  rheumatic  pericar- 
ditis in  St.  George's  Hospital  is  fifteen  days. 

Prognosis. — Simple  cases  of  pericarditis,  and  rheumatic  pericardi- 
tis, are  not  often  fatal,  and  a  favorable  prognosis  may  be  expressed  in 
a  very  large  projDortion.  As  an  intercurrent  disease,  coming  on  in  the 
course  of  certain  grave  maladies,  it  is  is  extremely  fatal.  Among 
these  may  be  mentioned  scorbutus,  pyaemia,  puerperal  diseases,  Bright's 
disease,  some  of  the  eruptive  fevers,  pneumonia,  etc. 

Diagnosis. — The  differentiation  of  pericarditis  from  endocarditis, 
hydropericardium,  and  left  pleurisy,  presents  some  points  of  difficulty. 
The  separation  of  the  endo-  and  exo-cardial  murmurs  is  often  an  affair 
of  extreme  nicety.  Dropsy  of  the  pericardium  is  to  be  distinguished 
from  the  inflammatory  affection  by  the  absence  of  fever,  local  pain, 
and  friction  murmur.  The  character  of  the  fluid  in  any  case  is  to  be 
determined  only  by  the  concomitant  circumstances.  If  the  patient  is 
scorbutic,  it  is  probably  haemorrhagic  ;  if  a  subject  of  chronic  alcohol- 
ismus,  it  may  be  haemorrhagic  ;  if  the  accompanying  malady  is  pyae- 
mia, or  a  septicaemic  process,  it  is  probably  purulent  ;  if  rheumatism, 
it  is  sero-fibrinous ;  if  albuminuria,  serous.  The  differentiation  of 
exo-  from  endo-cardial  murmurs  is  based  on  the  character,  quality, 
seat,  and  persistence  of  the  sounds.  The  friction  murmur  is  a  sound 
of  rasping,  of  crackling  ;  the  endocardial  murmur  is  softer,  smoother. 
The  friction  murmur  may  be  local  or  general,  and  has  no  constant  rela- 
tion to  the  orifices  of  the  heart  ;  the  endocardial  murmur  is  heard  with 
maximum  intensity  within  certain  valve  areas.  The  friction  murmur 
is  not  regularly  isochronous  with  the  valve-sounds,  or  with  the  cardiac 
rhythm  ;  the  endocardial  murmurs  are  usually  systolic  or  disastolic, 
or  coincide  with  the  rhythmic  movements  of  the  heart.  The  friction 
murmur  continues  where  it  began  ;  the  endocardial  murmurs  are  prop- 
agated in  the  direction  of  the  blood-current — basal  or  ajDical.  The 
friction  murmur  varies  from  one  hour  to  another  in  intensity  and  ex- 
tent ;  the  endocardial  murmurs  remain  constant.  The  friction  mur- 
mur increases  with  pressure  of  the  stethoscope  on  the  chest-wall ;  the 
endocardial  murmurs  are  not  affected  by  pressure.  The  friction  mur- 
mur increases  in  loudness  with  the  upright  position  and  bending  for- 
ward ;  the  endocardial  murmurs  are  most  distinct  in  the  recumbent 
posture.  The  friction  murmur  disappears  when  the  effusion  reaches 
a  certain  amount,  and  reappears  for  a  short  time  when  absorption  has 
taken  place  ;  the  endocardial  murmurs  are  permanent.  The  friction- 
sound  of  pleuritis  is  synchronous  with  the  respiration  ;  the  pericardial 
is  synchronous  with  the  cardiac  movements,  or  nearly  so  ;  suspension 
of  respiration  arrests  the  former,  but  does  not  affect  the  latter.     When 


PERICARDITIS.  23Y 

that  portion  of  the  pleura  in  contact  with  the  pericardium  is  the  seat 
of  inflammation,  a  friction  murmui-,  synchronous  with  the  cardiac 
movements  ;  in  that  case  the  distinction  is  impossible.  In  pleuritic 
effusion,  as  a  rule,  the  dullness  changes  with  the  position  of  the  pa- 
tient, and  in  the  upright  position  is  over  the  inferior  part  of  the  tho- 
rax. In  pleuritis  with  effusion,  all  voice  and  breath  sounds  disappear; 
in  pericarditis,  they  are  unaffected,  except  in  so  far  as  the  lung  is  dis- 
placed by  the  enlarging  pericardium.  In  hyj^ertrophy  of  the  heart, 
the  action  is  heaving,  and  the  apical  impulse  is  strong  ;  in  pericardi- 
tis, with  or  without  effusion,  the  impulse  becomes  weaker,  and,  as  the 
effusion  increases,  the  apical  impulse  will  cease,  or  at  least  greatly  di- 
minish in  force.  In  hypertrophy  the  absolute,  in  effusion  the  rela- 
tive, dullness  is  increased  ;  and,  as  has  been  pointed  out,  dullness 
exists  beyond  the  apex  of  the  heart  when  the  effusion  is  large. 

Treatment. — If  the  initial  symptoms  are  recognized,  a  full  dose  of 
quinia  sulphate  (3j)  should  be  administered,  with  a  half  grain  of  mor- 
phia, and  the  cinchonism  should  be  maintained,  by  repeated  smaller 
doses,  for  twenty-four  hours  or  longer.  When  the  evidence  of  effu- 
sion exists,  there  is  no  longer  any  indication  for  the  use  of  quinia, 
since  the  inflammatory  process  has  passed  beyond  control.  The  next 
object  of  treatment,  and  that  which  usually  engages  our  attention  at 
once,  is  the  management  of  the  exudation.  There  can  be  no  question, 
at  present,  respecting  the  influence  of  ammonia  salts  in  lessening  the 
coagulability  of  the  fibrinogenous  substance.  The  carbonate  should  be 
given  in  solution  of  the  acetate — five  grains  every  two  hours — when 
the  exudation  is  forming,  and  to  procure  its  disintegration  and  absorp- 
tion, thus  preventing  adhesions. 

When  the  initial  symptoms  make  their  appearance,  if  the  patient 
is  robust,  six  to  ten  leeches  should  be  applied  to  the  epigastric  region; 
they  should  be  allowed  to  fill  and  fall  off,  but  the  bleeding  should  not 
be  encouraged.  Dry  cups  may  be  applied  to  the  same  point,  if  the 
condition  be  that  of  debility.  With  or  without  previous  abstraction 
of  blood,  if  the  patient  is  not  depressed  and  the  action  of  the  heart 
feeble,  an  ice-bag  should  be  applied  to  the  prsecordia  during  the  initial 
period,  but  this  expedient  ceases  to  be  useful  when  there  is  much  exu- 
dation, and  may  be  very  injurious  if  the  heart  is  weakened  by  myocar- 
ditis. When  the  time  comes  for  the  removal  of  ice,  good  results  may 
be  expected  from  the  ajjplication  of  fiying-blisters.  As  a  condition  of 
quietude  of  the  diseased  organ  is  a  measure  of  the  highest  utility,  rem- 
edies which  slow  the  heart  are  necessary.  Aconite-root  tincture  and 
veratrum-viride  tincture  may  be  given  to  quiet  the  heart  before  con- 
siderable damage  has  been  done.  When,  however,  the  heart  begins 
to  flag,  remedies  of  a  dej)ressing  kind  are  not  suitable,  and  then  digi- 
talis becomes  extremely  serviceable,  not  only  to  lessen  the  work  of 
the  heart,  but  to  promote  absorption.     The  infusion  is  the  best  form, 


238  DISEASES   OF   THE   HEART. 

and  it  sliould  be  given  in  a  tablespoonful-dose  every  four  hours.  The 
absorption  of  a  pericardial  effusion  may  be  hastened  by  the  use  of  jab- 
orandi,  or  better,  its  active  principle — pilocarpine — so  administered  as 
to  act  freely  on  the  skin.  But  jaborandi  is  too  dej^ressing  a  remedy 
when  the  action  of  the  heart  is  feeble,  and  the  pulse  is  small  and  irreg- 
ular. Stimulant  doses  of  quinia  and  alcoholic  stimulants  are  very 
important  when  the  powers  are  failing  and  syncopal  attacks  are  occur- 
ring. Mechanical  means  are  proper  when  the  effusion  into  the  peri- 
cardial sac  is  great  and  does  not  yield  to  the  remedies  proposed. 
Paracentesis  of  the  pericardium  has  now  been  performed  many  times 
with  success,  so  that  it  can  no  longer  be  regarded  as  a  doubtful  experi- 
ment. .  The  hypodermic  syringe  may  be  used  to  ascertain  the  character 
of  the  effusion.  The  needle,  as  in  the  operation  for  capillary  puncture, 
is  inserted  close  to  the  border  of  the  sternum,  in  the  fifth  intercostal 
space.  The  operation  of  paracentesis  is  required  when  the  effusion  is 
great,  or  when  it  is  purulent.  If  the  effusion  returns  repeatedly,  it  is 
safe  practice  to  inject  the  tincture  of  iodine  (  3  ij —  f  iv)  to  prevent  the 
reaccumulation.  If  the  contents  of  the  sac  are  purulent,  the  iodine 
should  be  used  more  freely  (  3  ij  of  the  tincture,  3  ss  potassium  iodide, 
and  I  iv  water).  To  avoid  wounding  the  heart,  the  jjatient  should  be 
recumbent  when  the  puncture  is  made.  The  disadvantages  of  the 
operation  are,  that  it  is  rarely  curative  ;  that  it  has  caused  a  pneumo- 
pericardium ;  that  the  fluid  is  quickly  replaced,  because  of  the  less- 
ened extravascular  pressure  ;  that  haemorrhages  take  place  by  rup- 
ture of  the  thin-walled  vessels  of  the  neo-membrane.*  Better  results 
are  claimed  from  the  operation  of  paracentesis  when  a  part  of  the  fluid 
is  drawn  at  a  time,  rather  than  all  at  once.  When  there  is  extreme 
debility,  the  patient  may  not  be  able  to  bear  the  loss  of  the  blood- 
serum  which  pours  into  the  sac  after  the  removal  of  the  fluid.  It  is 
highly  important  to  maintain  the  powers  of  life  by  suitable  alimenta- 
tion from  the  beginning.  Stimulants  should  also  be  moderately  ad- 
ministered at  an  early  period,  and  be  given  freely  when  cardiac  failure 
is  threatened.  The  author  has  not  mentioned  the  so-called  sorbefa- 
cients,  calomel,  and  iodide  of  potassium,  because  the  first  named  has 
no  influence  over  the  inflammation,  and  is,  besides,  highly  iinfavorable 
to  the  process  of  repair,  and  the  latter  is  useless,  except  locally.  As 
the  pericardium  is  a  closed  sac,  and  as  effusions  into  it  are  not  affected 
by  diuretics,  they  have  not  been  considered  among  the  remedies. 

ADHESIONS  OF  THE   PERICARDroM. 

Nature. — Adhesions  of  the  two  pericardial  surfaces  are  results  of 
pericarditis.  They  occur  in  a  variety  of  forms  :  as  narrow  bands,  as 
membranif  orm  partitions,  dividing  the  cavity  into  several  smaller  cavi- 

*  Jaccoud,  "  Pathologie  Interne,"  toI.  i,  p.  535. 


ADHESIONS  OF   THE  PERICARDIUM.  239 

ties,  and  sometimes  these  secondary  sacs  contain  exudation,  in  the  form 
of  a  caseous  mass,  or  dark-brown  deposits,  a  product  of  altered  blood. 
The  adhesion  may  be  total,  so  that  after  some  years  no  line  of  union 
can  be  made  out  between  the  two  surfaces.  The  mass  of  exudation 
uniting  the  surfaces  may  be  converted  into  an  ajDparently  bony  case 
enveloping  the  heart  by  calcareous  deposition.  Bands  of  adhesion  may 
exist  externally  to  the  pericardium,  and  unite  this  membrane  to  the 
neighboring  pulmonary  pleura,  to  the  pleura  costalis  in  front,  to  the 
mediastinum,  etc.  As  has  been  pointed  out  in  the  preceding  chapter, 
an  inflammation  of  the  pericardium  leads  to  acute  myocarditis — an 
acute  fatty  degeneration  of  the  muscular  tissue.  Hypertrophy  and 
dilatation  are  among  the  results  of  adhesions.  Opinions  are  divided 
as  to  the  precise  part  played  by  the  adhesions,  but  there  can  be  no 
doubt  that  atrophy  with  hyperplasia  of  the  connective  tissue  are  results 
of  the  myocarditis,  which,  in  turn,  induces  dilatation  of  the  cavities. 
When  the  cavity  of  the  pericardium  is  obliterated,  and  adhesions  have 
been  contracted  to  neighboring  parts  also,  the  heart  works  to  great  dis- 
advantage; but  the  most  serious  result  is  the  interference  with  the  nu- 
trition of  the  organ.  On  the  other  hand,  there  may  be  entire  adhesion 
of  the  two  pericardial  surfaces,  and  the  heart  be  not  at  all  incommoded. 
Symptoms. — The  disturbances  produced  by  adhesions  are  mani- 
fested in  rational  and  physical  signs.  The  propelling  power  of  the 
heart  being  diminished,  stasis  takes  place  in  the  right  cavities,  in  the 
lungs,  and  venous  system  generally.  There  are  therefore  constantly 
present  bronchial  catarrh  ;  difficulty  of  breathing  ;  swollen  liver  and 
spleen  ;  gastro-intestinal  catarrh  ;  urine  scanty,  high-colored,  and  albu- 
minous ;  veins  full,  face  cyanosed  ;  general  dropsy.  The  apical  im- 
pulse is  either  wanting  entirely,  or  is  a  mere  tremor  ;  the  pulse  is  rather 
quick,  but  low  in  tension,  and  the  volume  varies  in  different  beats. 
These  rational  symptoms  are  chiefly  indicative  of  the  degeneration  and 
atrophy  which  have  occurred  in  the  heart -muscle.  Other  symptoms 
are  caused  by  adhesions.  One  of  the  most  important  physical  signs 
of  pericardial  adhesions  is  a  depression  with  the  systole  of  the  heart 
at  the  place  of  the  apex-beat.  Instead  of  an  elevation  of  the  inter- 
costal space  when  the  apex  of  the  heart  is  tilted  against  it  at  the  time 
of  the  systole,  there  occurs  a  de^yression,  or  draioing  in  of  the  chest- 
wall.  There  may  also  be,  at  the  left  of  the  sternum,  several  small  de- 
pressions or  "  pittings  "  in  the  intercostal  spaces.  These  depressions 
are  frequently  due  to  pericardial  adhesions  of  the  two  surfaces,  and  to 
the  parietal  pleura  ;  but  they  may  occur  independently  of  this,  as  has 
been  demonstrated  by  Friedreich,  produced  by  causes  which  obstruct 
the  downward  movement  of  the  heart  toward  the  left,  and  the  tilting 
of  the  apex  upward,  the  lungs  at  the  same  time  not  coming  forward 
sufficiently.  A  diastolic  elevation  of  the  chest-wall  is  the  compensatory 
sign  of  the  preceding  elevation.    When  the  force  producing  the  other 


240  DISEASES   OF   THE   HEART. 

ceases  to  act,  there  is  a  rebound  of  the  chest-wall,  which,  if  not  visible 
to  the  eye,  may  be  felt  on  palpation.  These  two  signs  are  highly  sig- 
nificant, but  their  absence  does  not  negative  the  existence  of  pericardial 
adhesions.  It  has  already  been  stated  that  the  area  of  absolute  dull- 
ness is  increased  in  those  cases  of  adhesions  which  fix  the  heart  against 
the  chest-wall,  and  do  not  permit  the  organ  to  fall-  back,  while  at  the 
same  time  the  lung  is  prevented  coming  forward.  If  the  heart  is  so 
fixed  in  position  by  adhesions,  and  is  at  the  same  time  hypertrophied, 
and  if  the  pericardium  be  adherent  to  the  chest-wall,  and  to  the  spine 
behind,  there  must,  of  necessity,  be  produced  the  systolic  depression. 
When  the  diastolic  rebound  ("  diastolic  concussion ")  occurs,  a  syn- 
chronous or  diastolic  collapse  takes  place  in  the  cervical  veins.  Much 
distended  during  the  systole,  they  suddenly  subside  and  even  disappear 
during  the  diastolic  rebound,  for  during  this  act  the  chest  is  expanded 
and  the  blood  is  drawn  into  the  cavity.  The  importance  of  pericardial 
adhesions  depends  much  less  on  the  adhesions  than  on  the  changes  in 
the  heart-muscle.  Adhesion  bands  connecting  the  two  surfaces  may 
exist  without  injurious  effects.  When  hypertrophy  takes  place  com- 
pensation ensues,  and  the  heart  is  equal  to  its  duties  for  many  years. 
On  the  other  hand,  when  the  heart-muscle  undergoes  atrophic  degen- 
eration, its  propelling  power  is  insufiicient,  venous  stasis  and  dropsy 
follow,  and  then  a  fatal  termination  is  near.  The  treatment  in  these 
cases  must  be  directed  to  the  nutrition  of  the  heart-muscle.  Rest 
must  be  enjoined  ;  the  appetite  and  digestion  must  be  improved  by 
bitters,  mineral  acids,  and  the  ferruginous  tonics.  The  heart  must  be 
toned  up  by  digitalis  and  iron,  and  by  the  judicious  administration  of 
quinia  and  morphia — the  latter  in  minute  quantity  (y^g  of  a  grain).  The 
author  has  seen  the  greatest  advantage  from  the  use  of  sulphate  of 
iron  (gr.  j),  sulphate  of  quinia  (gr.  ij),  sulphate  of  morphia  (gr.  ^^), 
and  digitalis  (gr.  j)  in  pill-form,  three  times  a  day. 

HYDROPERICARDIUM— DROPSY  OF   THE  PERIOARDroM. 

Pathogeny. — By  hydropericardium  is  meant  an  accumulation  of 
water  in  the  sac  of  the  pericardium  without  the  occurrence  of  inflam- 
mation. After  death,  especially  from  chronic  wasting  diseases,  there 
will  be  often  found  in  the  sac  an  ounce  or  two  of  fluid,  poured  out  at 
the  time  of  the  death-agony  and  immediately  after.  In  dropsy,  prop- 
erly speaking,  the  quantity  of  fluid  may  reach  to  one  or  two  pints.  It 
is  a  clear,  yellowish,  or  straw-colored  serum,  usually,  but  it  may  present 
a  somewhat  turbid  appearance  from  the  presence  of  cast-off  epithelium, 
or  a  bloody  appearance  derived  from  hfematin.  This  fluid  has  the 
composition  of  the  blood-serum,  and  its  alkaline  reaction,  but  does  not 
contain  the  same  relative  proportions  of  its  constituents.  The  albu- 
men is  less  than  in  the  blood-serum,  and  also  some  of  the  salts  ;  but  it 


HYDROPERICARDIUM.  241 

contains  the  fibrinogenous  substance  which  sometimes  coagulates  when 
exposed  to  air.  Urea  is  found  in  this  fluid  in  renal  diseases,  and  it  is 
stained  with  bile-pigment  in  cases  of  jaundice.  The  fluid,  if  large  in 
amount,  dilates  the  sac,  and  its  walls  become  thinned  by  the  pressure, 
and  often  present  a  sodden  appearance  when  there  has  been  a  protracted 
contact  of  the  fluid  with  the  endothelium.  The  subserous  fat  is  ab- 
sorbed by  the  pressure,  and  the  areolar  tissue  is  infiltrated  with  fluid. 

The  causes  of  hydropericardium  are  twofold  :  mechanical  and  dys- 
crasic.  Diseases  or  neoplasms,*  that  interfere  with  the  return  of  blood 
through  the  veins,  as  tumors,  obstructive  pulmonary  disease,  emphy- 
sema, and  dyscrasia,  such  as  Bright's  disease,  cancer,  and  tuberculosis, 
are  the  principal  etiological  factors. 

Symptoms. — A  small  quantity  of  fluid  will  not  produce  sufficient 
disturbance  to  cause  recognizable  symptoms  ;  a  large  effusion  will  be 
recognized  by  the  rational  and  physical  signs,  such  as  were  described 
under  pericarditis,  with  effusion.  There  is,  of  course,  no  friction  mur- 
mur. The  apical  impulse  becomes  more  and  more  feeble  as  the  effu- 
sion increases,  and  it  ultimately  ceases  to  be  felt.  The  heart-sounds 
grow  more  and  more  feeble,  and  may  disappear  entirely.  The  area  of 
relative  dullness  greatly  increases  and  extends  finally  beyond  the  region 
of  apex-beat,  and  has  the  characteristic  triangular  form  of  dullness  from 
effusion.  The  diagnosis  of  hydropericardium,  from  the  effusion  of  peri- 
carditis, rests  entirely  on  the  history — the  latter  being  due  to  inflam- 
mation, the  former  not.  The  prognosis  of  this  malady  is  serious,  not 
wholly  because  of  the  fluid,  but  on  account  of  the  conditions  associ- 
ated with  it.  The  treatment  is  directed  to  the  removal  of  the  fluid, 
and  consists  in  the  use  of  eliminants  and  mechanical  means  ;  purgatives, 
diaphoretics,  and  diuretics  are  employed  to  procure  absorption.  Saline 
purgatives,  compound  jalap  powder,  elaterium,  are  given  to  diminish 
blood-pressure  and  the  quantity  of  fluid  ;  squill,  digitalis,  and  cream- 
of -tartar,  to  excite  diuresis  ;  warm  baths  and  pilocarpine  to  stimulate 
the  skin.  These  means  may  be  entirely  successful  in  some  few  cases 
in  Bright's  disease,  for  example,  but  will  have  but  little  effect  in  cases 
of  emphysema,  tuberculosis  of  the  lungs,  and  when  the  effusion  is  due 
to  the  pressure  of  a  tumor.  Aspiration  is  proper  when  life  is  threat- 
ened by  the  extent  of  the  effusion,  but  there  is  danger  of  exciting  peri- 
carditis and  of  the  admission  of  air.f 

HYDROPNEUMOPBRIOARDIUM. — This  form  of  disease  differs 
from  the  preceding  in  that  air  or  gas,  as  well  as  fluid,  is  present  in  the 
cavity.  The  fluid,  when  gas  is  also  present,  is  composed  of  some  de- 
composing exudation,  of  pus,  or  of  blood.     The  first  named  is  derived 

*  "Transactions  of  the  Pathological  Society  of  London,"  vol.  xxii,  p.  123. 
t  Roberts,   "  Paracentesis  of  the  Pericardium."     Philadelphia,  1880.    An  excellent 
work. 

16 


242  DISEASES   OF   THE   HEART. 

from  pericarditis,  the  result  of  traumatism,  or  excited  by  an  ulceration 
penetrating  the  cavity  from  the  neighboring  parts.  The  symptoms  are 
physical.  The  space  of  absolute  dullness  is  occupied  by  a  tympanitic 
sound,  except  at  the  base,  where  it  is  dull  from  the  presence  of  fluid. 
Change  of  the  patient's  posture  alters  the  position  of  the  dullness.  The 
heart-sounds  and  the  apical  impulse  are  sometimes  feeble  and  may  not 
be  perceptible,  but  are  usually  loud,  splashing,  and  prominent.  A  pe- 
culiar, clanging,  metallic  character  is  imparted  to  the  heart-sounds. 
The  friction  murmur  has  a  rough,  rasping,  metallic  resonance.  Yery 
remarkable  sounds  are  produced  by  the  churning  of  the  liquid  and  air 
together  by  the  heart-movements,  and  are  designated  "the  water- 
wheel  sounds."  The  functional  disturbances  produced  by  hydropneu- 
mopericardium  are  those  of  pericarditis,  and  need  not  therefore  be  re- 
capitulated. The  prognosis  is  grave  ;  yet,  of  fourteen  cases  collected 
by  Friedi'eich,  only  ten  proved  fatal.  It  has  usually  been  regarded  as 
more  fatal  than  these  figures  indicate.  It  is  probable  that  some  of 
them  were  examples  of  the  admission  of  air  merely,  and  were  not 
produced  by  the  gas  of  decomposition.  The  treatment  is  that  of  peri- 
carditis. The  presence  of  decomposing  materials,  or  such  an  excess  of 
gas  or  fluid  as  to  exercise  dangerous  compression,  justifies  the  employ- 
ment of  the  aspirator,  and  washing  out  the  sac  with  an  iodine  solution. 

INFLAMMATION   OF   THE   MUSCULAR   TISSUE  OF   THE   HEART 

—MYOCARDITIS. 

Definition. — The  cardiac  muscle  is  subject  to  attacks  of  inflamma- 
tion, as  muscular  tissue  in  other  situations.  The  term  myocarditis 
includes  several  morbid  conditions  of  an  analogous  kind,  but  different 
in  seat  and  also  in  progress. 

Causes. — The  male  sex  is  more  liable  than  the  female.  The  acute 
form  is  more  common  before  than  after  thirty  years  of  age.  Myocar- 
ditis may  occur  during  intra-uterine  life,  and  then  preferably  on  the 
right  side,  setting  up  important  changes.  It  is  supposed  that  chilling 
the  body,  suddenly,  when  in  a  warm  and  perspiring  state,  will  cause 
this  disease  ;  again,  violent  muscular  exertion  is  said  to  have  excited 
inflammation  ;  but  these  are  very  doubtful  causes.  In  fact,  nothing  is 
definitely  known  of  the  influences  setting  up  such  a  morbid  process  in 
the  heart-muscle.  As  regards  the  secondary  diseases,  our  information 
is  more  definite.  It  has  already  been  pointed  out  that  myocarditis  is 
a  result  of  pericarditis,  the  inflammation  extending  by  contiguity  of 
tissue.  It  results  from  valvular  lesions  also,  and  may  be  secondary  to 
the  acute  infectious  diseases — as  typhoid,  pysemia,  scarlet  fever,  etc. 
Inflammation  and  abscess  may  be  the  result  of  embolic  obstruction 
of  the  coronary  artery. 

Pathological  Anatomy. — The  muscular   tissue  itself,  or  its  inter- 


MYOCARDITIS.  243 

vening  connective  tissue,  may  be  the  seat  of  the  inflammatory  action  ; 
consequently  there  are  two  forms — parenchymatous  and  interstitial. 

1l\xq, parenchymatous  may  occur  in  two  forms  ;  in  isolated  patches, 
or  generally  diffused.  "When  a  large  part  of  the  organ  is  attacked, 
there  is  a  marked  change  in  its  appearance.  The  muscular  tissue  has 
a  reddish  color,  is  puffy  in  appearance,  and  the  pericardium  is  spotted 
with  points  of  ecchymoses,  is  cloudy,  and  coated  here  and  there  with 
a  delicate  exudation.  The  muscular  tissue,  on  microscopical  examina- 
tion, is  found  to  be  cloudy,  granular,  and  swollen,  and  the  striae  indis- 
tinct or  absent,  or  the  fibers  are  broken  up  into  granular  fragments, 
are  crowded  with  fat-granules,  and  ultimately  are  replaced  by  rows  of 
fat-granules.  When  the  change  is  far  advanced,  the  muscle  is  brown- 
ish in  color,  and  almost  or  quite  piilpy  in  consistence.  This  change 
may  extend  over  large  parts  of  the  organ,  or  may  be  confined  to  spots 
or  isolated  patches,  and  certain  parts  of  the  heart  are  especially  apt  to 
suffer,  as  the  apex  of  the  left  ventricle,  and,  at  the  base,  the  posterior 
wall ;  next,  the  aortic  valves  adjacent  to  the  septum,  then  the  papil- 
lary muscle,  and,  on  the  right  side,  the  muscular  trabeculse. 

Interstitial  myocarditis  also  occurs  in  two  forms  :  the  suppurative 
and  the  sclerotic  ;  the  former  being  acute,  the  latter  chronic.  Suppu- 
rative interstitial  myocarditis  usually  coincides  with  the  parenchyma- 
tous ;  and,  between  the  muscular  elements  disintegrating  with  acute 
fatty  degeneration,  is  seen  more  or  less  extensive  dissemination  of  pus, 
or  distinct  and  isolated  collections,  or  abscesses.  When  the  suppu- 
ration is  due  to  emboli,  the  purulent  collections  are  small,  and  there 
are  usually  several ;  when  the  result  of  interstitial  inflammation,  there 
is  usually  a  single  large  one.  An  abscess  may  rupture  outwardly  into 
the  sac  of  the  pericardium,  or  inwardly  into  the  cavity  of  the  heart. 
If  situated  in  the  septum,  by  the  discharge  a  communication  is  estab- 
lished between  the  two  ventricles,  or  it  may  cause  a  rupture  of  a  seg- 
ment of  the  semilunar  valve,  an  example  of  which  has  fallen  under 
the  author's  observation.  Again,  an  abscess  in  the  walls  discharging 
into  the  ventricle,  forms  a  sac  which,  bulging  outwardly  under  the 
blood-pressure,  becomes  an  "  aneurism  of  the  heart,"  so  called.*  The 
interior  of  such  a  sac  becomes  lined  with  successive  layers  of  fibrin, 
■which  protects  the  cavity  from  rupture,  but  only  for  a  brief  period. 
When  an  abscess  discharges  into  the  pericardium,  a  fatal  pericarditis 
results  ;  when  the  purulent  matters  and  shreds  of  broken-down  tissue 
enter  the  cavity,  they  produce  the  disastrous  results  of  multiple  embo- 
lisms.f     Rarely,  the  pus  is  absorbed,  and  a  mass  of  connective  tissue 

*"  Transactions  of  the  Pathological  Society  of  London,"  vol.  xix,  p.  149  (with 
plate). 

f  Ibid.,  vol.  XX.  "  A  case  of  abscess  of  the  heart  bursting  into  the  left  ventricle." 
Boy  of  eleven  years  had  a  fall  and  hurt  his  shoulder ;  had  delirium,  wakefulness,  and 
fever,  and  a  very  rapid  pulse,  but  no  cardiac  symptoms.     Died  on  thirteenth  day. 


244  DISEASES   OF   THE  HEART. 

and   a  puckered   cicatrix   remain   to  indicate  the  nature  of  the  dis- 
ease. 

The  chronic  interstitial  myocarditis  is  sometimes  called  sclerosis 
of  the  heart,  or  fibroid  degeneration  (Legg)  of  the  heart.  It  consists 
in  a  proliferation — an  overgrowth — of  the  connective  tissue  and  an 
atrophy  of  the  proper  muscular  elements.  There  may  be  small  bands 
of  connective  tissue  stretching  between  the  muscular  fibers,  or  larger, 
firm  bands,  or  indurated  masses,  which  take  the  place  of  muscular  tis- 
sue entirely.  These  bundles  or  masses  of  connective  tissue  occur  in 
the  papillary  muscle  of  the  left  ventricle  and  in  the  walls,  but  more 
toward  the  apex  than  at  the  base.  Two  evils  result  from  the  pres- 
ence of  these  bands  and  masses  of  connective  tissue  and  from  the  re- 
sulting muscular  atrophy  :  the  propelling  power  of  the  heart  is  re- 
duced and  stasis  occurs  in  the  venous  system  ;  the  walls  yield  at  those 
places  composed  of  the  connective  tissue,  and  form  the  so-called  "par- 
tial aneurism  of  the  heart."  It  is  especially  at  the  apex  of  the  left 
ventricle  (eighty-five  in  eighty-seven  cases)  that  these  aneurisms  form. 
They  vary  in  size  from  a  pigeon's  to  a  hen's  ^gg,  are  irregular  and 
divided  by  partitions  and  often  have  diverticula  attached,  and  they 
contain  old  deposits  of  fibrin  and  recent  soft  coagula.  The  walls  of 
these  partial  aneurisms  are  composed  of  the  sclerotic  material,  the  en- 
docardium, and  the  visceral  layer  of  the  pericardium  with,  it  may  be, 
the  parietal  layer  attached.* 

Symptoms. — The  existence  of  myocarditis  can  hardly  ever  be  any- 
thing but  a  presumption,  based  on  negative  rather  than  positive  signs. 
If  maladies  are  present,  as  rheumatism,  pyaemia,  puerperal  fever,  etc., 
in  the  course  of  which  myocarditis  may  be  expected,  if  the  symp- 
toms of  cardiac  failure  come  on  suddenly,  and  if  they  can  not  be 
referred  to  an  endocarditis  or  pericarditis,  then  the  existence  of  in- 
flammation of  the  heart-substance  may  be  suspected.  When  this  dis- 
ease occurs  as  secondary  to  rheumatic  endo-  or  pericarditis,  the  patient 
passes  rapidly  into  that  condition  of  profound  adynamia  known  as  the 
typhoid  state.  When  an  abscess  discharges  its  contents  into  the  cavity 
of  the  heart,  the  symptoms  of  multiple  embolisms  are  produced  ;  there 
are  repeated  violent  chills,  very  high  febrile  temperature,  profuse 
sweats,  icterus,  swollen  spleen,  albuminuria,  delirium,  or  the  disturb- 
ances due  to  embolism  of  the  cerebral  vessels,  etc.  The  yielding  of 
the  sclerosed  tissue  and  the  formation  of  the  so-called  aneurisms  are 
announced  by  failure  of  the  heart ;  the  pulse  becomes  thready,  the 
lips  blue,  the  face  anxious,  livid,  and  cyanosed,  the  respiration  em- 
barrassed, the  surface  cold,  the  weakness  extreme,  death  occurring  in 
a  short  time  in  syncope. 

Those  cases  of  myocarditis  in  which  the  symptoms  of  embolism 

-...  *  Ponfick,  Virchow's  "  Archiv,"  Band  Iviii,  p.  528. 


FATTY   HEART.  245 

are  wanting,  and  aneurismal  dilatations  have  not  occurred,  are  char- 
acterized by  the  presence  of  the  following  signs  :  The  movement  of 
the  heart  is  feeble,  and  the  apical  impulse  unfelt ;  the  pulse  is  small, 
weak,  irregular,  and  intermittent.  The  great  diminution  which  has 
taken  place  in  the  propulsive  power  of  the  heart  manifests  itself  in 
stasis,  pulmonary  engorgement  and  oedema,  cyanosis  of  the  face,  swol- 
len veins,  vertigo,  delirium,  etc.  In  the  so-called  chronic  partial  aneu- 
rism, there  may  be  no  symptoms  for  a  time  to  indicate  the  existence 
of  the  lesions.  We  have  here  the  same  groups  of  symptoms,  due  to 
the  diminished  propelling  power  of  the  heart,  as  in  the  preceding 
paragraph,  when  sufficient  damage  has  been  done  to  cause  yielding  of 
the  cardiac  wall. 

Course,  Duration,  and  Termination. — The  course  of  the  acute  form 
of  myocarditis  is  very  rapid,  and  the  duration  from  two  or  three  to 
eight  days,  but  some  of  them  terminate  in  a  few  hours.  Death  may 
be  due  to  rupture  of  the  heart,  to  cerebral  emboli,  to  pulmonary  oedema, 
to  paralysis  of  the  heart,  etc.  Chronic  myocarditis  pursues  a  very 
latent  course.  The  development  of  the  lesions  may  be  slow,  and 
hence  the  duration  may  be  prolonged,  but  not  indefinitely.  Dilata- 
tion of  the  cavities,  feebleness  of  action,  and  stasis,  will  bring  on 
fatal  lesions  in  a  few  months,  or,  at  most,  a  year  or  two. 

Treatment. — The  treatment  must  be  largely  symptomatic,  and  for 
parenchymatous  carditis  is  to  the  last  degi'ee  inefficient,  since  the 
causes  are  not  to  be  removed.  Interstitial  inflammation,  like  the  same 
disease  elsewhere,  is  little  influenced  by  remedies.  Minute  doses  of 
chloride  of  gold,  or  of  corrosive  chloride  of  mercury,  quiniae,  and 
digitalis,  offer  the  best  prospect  of  improvement.  The  utmost  qui- 
etude of  mind  and  body  must  be  maintained.  A  generous  diet  and 
means  to  promote  digestion  are  necessary  to  improve  the  quality  of 
the  blood. 

FATTY  DEGENERATION  OP  THE   HEART. 

Definition. — A  distinction  must  be  drawn  between  fatty  degenera- 
tion and  fatty  substitution  :  the  former  implying  a  change  in  the  struc- 
ture of  the  muscular  tissue;  the  latter,  a  displacement  of  the  muscular 
tissue,  in  which  atrophy  of  the  muscular  elements  may  take  place,  by 
the  pressure. 

Causes. — The  nvitrition  of  the  heart  is  impaired  by  a  variety  of 
causes,  intrinsic  and  extrinsic.  Among  the  intrinsic  are  pericarditis 
and  myocarditis,  which  set  up  an  inflammation  of  the  heart-muscle  ; 
diminished  blood-supply  due  to  atheroma  ;  compression,  etc.,  of  the 
coronary  arteries  ;  fat  substitution,  which,  encroaching  on  the  proper 
tissue  of  the  organ,  causes  absorption,  etc.  Among  the  extrinsic 
causes  are  impaired  nutrition  in  general,  originating  in  various  ways — 
cancer,  tuberculosis,  scrofula,  prolonged  suppuration,  prolonged  lac- 


^ 


246  DISEASES   OF   THE   HEART. 

tation,  etc.  Most  of  the  foregoing  causes  induce  atrophy  by  setting 
up  a  fatty  degeneration.  Anaemia,  especially  when  extreme  and  long- 
continued,  has  a  strong  tendency  to  induce  this  change.  This  has 
been  demonstrated  experimentally  by  Perl,*  and  clinically  by  Ponfick  f 
and  others.  In  the  various  causes  above  given  it  is  the  condition  of 
anaemia  induced  by  them  which  is  responsible  for  the  changes  in  the 
heart's  muscular  tissue.  Infectious  diseases,  fevers,  and  certain  poi- 
sons, notably  phosphorus  and  alcohol,  bring  on  fatty  degeneration. 
The  same  result  is  produced  by  the  mineral  poisons  in  general,  but  to 
a  less  degree,  and  some  other  substances.  Fatty  deposition  sometimes 
takes  place  to  a  dangerous  extent  in  the  obese,  along  the  sulcus,  and 
penetrating  to  the  endocardium.  Furthermore,  in  the  anaemia  of  the 
obese,  sometimes  a  very  marked  condition — fatty  degeneration  of  the 
heart-muscle — comes  on. 

Pathological  Anatomy. — The  change  may  be  general  or  diffused,  or 
exist  in  spots  and  patches.  The  color  becomes  yellowish,  the  tissue 
soft  and  easily  torn,  and  on  the  touch  makes,  in  advanced  cases,  a  dis- 
tinctly greasy  impression.  The  initial  change  is  in  the  primitive  bun- 
digs,  which  become  cloudy,  granular,  and  their  striae  disappear.  Minute 
oil-globules  appear,  and  are  soon  seen  in  rows,  but  they  presently 
coalesce  ;  large  globules  are  formed,  and  nothing  is  then  visible  in  the 
sarcolemma  but  a  multitude  of  fat-drops.  With  this  change  in  the 
fibrilke  of  muscle,  an  oedematous  condition  of  the  sub-serous  connective 
tissue  occurs,  and  the  nutrient  vessels  are  advanced  in  calcareous  de- 
generation. The  fatty  change  may  occupy  the  walls  of  the  left  ven- 
tricle, or  be  confined  to  isolated  patches  here  and  there  in  the  walls  of 
the  heart,  the  papillary  muscle,  the  trabeculae,  the  septum,  etc.  In 
the  cases  of  fatty  substitution,  the  whole  heart  may  be  enveloped  in  a 
dense  layer  of  fat,  which  also  pushes  its  way  into  the  muscle,  follow- 
ing the  inter-muscular  planes  and  the  connective  tissue,  causing  such 
compression  that  the  muscular  fibers  undergo  atrophy,  and  are  pale, 
thin,  and  wanting  in  contractile  power. 

Symptoms. — Weakening  of  the  heart,  produced  by  fatty  change  in 
its  muscles,  causes  the  disturbances  due  to(^f(9lmia  of  the  organs  and 
to  venous  stasis.  The  rational  are  more  significant  than  the  physical 
signs.  On  palpation,  the  apical  impulse  is  weak.  On  percussion,  there 
is  nothing  distinctive,  except  an  increase  of  the  area  of  absolute  dull- 
ness, if  the  organ  is  enlarged  by  dilatation  of  its  cavities.  As  there  is 
venous  stasis,  and  as  the  right  cavities  yield  more  than  the  left,  the 
area  of  dullness  is  increased  over  the  lower  end  of  the  sternum  to  the 
xiphoid  appendix.  On  auscultation,  if  there  be  fatty  degeneration  of 
the  papillary  muscle,  a  systolic  murmur  is  audible  in  the  mitral  area. 

*  "  Ueber  deu  Einfluss  der  Anamie  auf  die  Ernahrung  des  Herzmuskels,"  Virchow's 
"Archiv,"  Band  lix,  p.  39. 

f  Ponfick,  "Berliner  klin.  Woeh.,"  "Ueber  Fetthcrz,"  Nos.  1  and  2,  ISYS. 


FATTY   HEART.  247 

The  sounds  of  the  heart  are  dull,  confused,  almost  inaudible,  and  there 
is  often  a  failui'e  of  synchronism  in  the  closure  of  the  valves,  causing 
double  sounds.  The  pulse  is  small,  irregular,  intermittent,  weak,  and 
easily  compressed,  and  may  be  very  slow,  falling  to  forty,  often  even 
as  low  as  twenty  ;  but  this  is  exceptional.  A  very  formidable  symp- 
tom, which,  however,  occurs  under  other  circumstances,  is  a  peculiar 
alteration  of  the  respiratory  rhythm,  known  as  the  Cheyne-Stokes 
breathing,  in  which  at  intervals  the  respiration  becomes  slower  and 
shallower,  until  finally  it  seems  to  cease — is  suspended  "for  some  sec- 
onds, half  a  minute,  for  a  minute — and  then  is  resumed,  slow  and  shal- 
low, but  gradually  attaining  its  normal  amplitude.  This  may  be  kept  up 
for  some  time,  then  disappear,  to  occur  again.  The  diminished  propul- 
sive power  of  the  heart,  causing  anremia  of  organs,  induces  character- 
istic symptoms.  Sudden  anaemia  of  the  brain,  faintness,  and  actual 
fainting,  often  occur  on  rising  up  suddenly  from  a  recumbent  pos- 
ture, stooping,  turning  around  quickly,  etc.  These  subjects  experi- 
ence constantly,  or  nearly  so,  a  sense  of  fullness  and  distention  about 
the  ensiform  cartilage  or  lower  sternum,  which  is  associated  with  prae- 
cordial  anxiety,  and  they  have  attacks  of  angina  pectoris,*  They 
experience  difficulty  of  breathing  on  slight  exertion,  and  can  not  ascend 
elevations  or  stairways  without  experiencing  great  distress.  The  veins 
of  the  neck  are  habitually  distended,  and  the  countenance  looks  dusky 
and  anxious.  The  legs  become  oedematous  ;  next,  the  body  generally; 
the  liver  enlarges,  ascites  forms,  the  urine  becomes  albuminous,  etc. 

Course,  Duration,  and  Termination. — Acute  fatty  heart,  produced 
by  the  action  of  poisons,  terminates  early  ;  but  the  eases  due  to  the 
ordinary  causes  proceed  more  slowly,  and  may  last  during  several 
years.  Their  development  is  obscure,  and  there  are  no  pronounced 
symptoms  until  those  of  failing  heart  come  on.  The  termination  is  in 
general  dropsy,  or  death  is  caused  by  oedema  of  the  lungs,  or  takes 
place  suddenly  by  paralysis  of  the  heart,  or  by  rupture  of  the  organ. 

Diagnosis. — If  the  causes  of  fatty  degeneration  have  existed,  and 
symptoms  of  cardiac  weakness  come  on  .slowly,  the  existence  of  fatty 
heart  may  be  regarded  as  probable,  but  the  diagnosis  is  largely  the 
balance  of  probabilities,  and  is  not  to  be  arrived  at  by  exclusion  with 
certainty. 

Treatment. — As  augemia  plays  so  important  a  part  in  the  causation 
of  fatty  degeneration  of  the  heart,  the  treatment  should  be  directed  to 
the  enrichment  of  the  blood.  Iron,  manganese,  and  strychnine  (the 
sulphateg),  is  an  excellent  combination.  The  author  has  seen  good  ^ 
results  from  the  phosphate  of  iron,  quinia,  and  strychnia,  in  the  form 
of  the  elixir.  Jaccoud  prefers  cafi^ein  to  digitalis  as  a  heart-tonic  in 
these  cases.     The  efficiency  of  opium,  or,  better,  small  doses  of  mor- 

*  J.  Lockhart  Clarke,  "  St.  George's  Hospital  Reports,"  vol.  iv,  p.  1. 


248  DISEASES   OF   THE   HEART. 

phia,  as  a  tonic  of  the  heart,  is  too  little  understood.  Especially  in 
the  form  of  hypodermatic  injection  is  it  useful,  as  demonstrated  by  Clif- 
ford Allbutt.  Inhalations  of  oxygen  gas,  the  internal  use  of  cod-liver 
oil,  and  faradization  of  the  muscles  generally,  are  expedients  of  high 
utility.    As  the  case  progresses,  symptoms  must  be  treated  as  they  arise. 

RUPTURE    OF    THE    HEART. 

Definition. — Under  the  designation  of  rupture  of  the  heart  is  meant 
the  so-called  spontaneous  rujDture,  in  contradistinction  to  rupture  by 
wounds  and  injuries. 

Pathogeny  and  Symptoms. — That  rupture  shall  occur  it  is  necessary 
I  that  the  walls  of  the  heart  be  weakened  by  disease.  The  most  fre- 
quent cause  is  fatty  degeneration,  for,  in  twenty-four  cases,  this  condi- 
tion of  the  muscular  tissue  was  found  in  nineteen,*  Next  in  impor- 
tance as  a  cause  is  the  softening  produced  by  acute  myocarditis,  espe- 
cially the  suppurative  form,  or  the  aneurisms,  so  called,  due  to  the 
changes  of  chronic  myocarditis.  Diseases  of  the  coronary  artery, 
tumors,  echinococci,  by  destroying  muscular  tissue,  lead  to  rupture. 
It  is  more  common  in  men  than  in  women,  and  in  old  age — after  sixty 
years.  As  to  the  site  of  the  rupture,  statistics  show  that  the  left  ven- 
tricle, at  or  near  the  apex,  next  the  right  ventricle,  then  the  right 
auricle,  are  the  most  usual ;  but  the  preponderance  is  immensely  on 
the  side  of  the  left  ventricle — forty-three  times  in  fifty-five  cases. 
There  is  usually  but  a  single  vent,  but  there  may  be  several,  and,  as 
they  follow  the  direction  of  the  muscular  bands  and  the  line  of  least 
resistance,  they  are  tortuous,  somewhat  jagged  in  their  margins,  and 
the  two  orifices  are  not  opposite.  The  size  of  the  rent  varies  from  an 
inch  to  the  whole  length  of  the  cavity.  The  pericardial  sac  contains 
more  or  less  blood,  according  to  the  size  of  the  opening.  The  rupture 
may  be  gradual,  a  part  yielding  at  a  time.  Death  may  take  place 
almost  instantaneously.  Usually,  a  groan  or  a  cry  is  uttered,  the  face 
grows  deadly  pale,  the  individual  falls  unconscious,  there  is  some  shud- 
dering, and  he  is  dead.  The  dying  may  extend  over  several  days — 
the  patient  experiencing  the  symptoms  of  angina  pectoris  several 
times  with  intervals  of  partial  relief,  death  occurring  suddenly  at  last. 
In  such  cases,  it  is  assumed  that  successive  portions  of  the  heart-wall 
yield,  or  that  clots  temporarily  obstruct  the  rent. 

The  treatment,  when  there  is  time  for  it,  is  purely  symptomatic. 

HYPERTROPHY  AND   DILATATION   OF  THE   HEART. 

Definition. — By  hypertrophy  of  the  heart  is  meant  an  increase  of 
size  of  the  organ,  because  of  an  addition  to  its  substance.  This  en- 
largement takes  several  directions,  as  follows  : 

*  "Berliner  klinische  Wochenschrift,"  IS'ZS,  p.  15  ;  Ponfick,  "Ueber  Fettherz." 


UYPERTROrriY   AND   DILATATION.  2J.9 

Simple  hypertrophy  means  an  increase  in  size  without  alteration  of 
the  cavities  ;  concentric  hy2')ertrophy  means  increase  in  thickness  of 
the  walls,  the  cavities  becoming  smaller  ;  excentric  hypertrophy  means 
increase  in  the  thickness  of  the  walls,  the  cavities  becoming  larger. 

The  dilatations  of  the  heart  correspond  in  arrangement  as  follows: 

In  simple  dilatation,  the  cavities  are  enlarged  while  the  walls  re- 
main normal  ;  in  active  dilatation,  which  corresponds  to  excentric 
hypertrophy,  the  cavities  are  enlarged,  and  the  walls  are  increased  in 
thickness  ;  in  passive  dilatation,  the  cavities  are  enlarged  and  the 
walls  are  thinner.     This  is  the  most  usual  form. 

The  conditions  attendant  on  hyi^ertrophy  and  dilatation  are,  in 
some  respects,  the  same;  so  that  it  is  an  economy  of  space,  and  con- 
tributes to  clearness  of  conception,  to  study  them  together. 

Causes — Hypertrophy. — Simple  hypertrophy,  which  is  by  no  means 
common,  arises  from  over-action  of  the  cardiac  muscle,  without  there 
being  any  disease  of  the  circulatory  apparatus.  The  over-action  is 
due  to  the  abuse  of  such  stimulants  as  coffee,  tea,  tobacco ;  to  moral 
emotions  and  intellectual  effort,  when  excessive  ;  to  repeated  muscular 
fatigue,  etc.  The  hypertrophy  resulting  in  this  way  is  general.  Any 
obstacle  to  the  free  circulation  of  the  blood  imposes  additional  work 
on  the  heart.  Narrowing  of  the  aortic  orifice  gives  the  left  ventricle 
more  work  to  do,  and  hence  its  muscular  fibers  undergo  hypertrophy  ; 
in  the  same  way,  hypertrophy  of  the  right  ventricle  results  from  nar- 
rowing of  the  pulmonary  orifice,  of  the  left  auricle,  from  mitral  steno- 
sis, and  of  the  right  auricle,  from  tricuspid  stenosis.  These  are  typical 
examples  of  partial  hypertrophy.  The  causes  of  obstruction  in  front, 
inducing  hypertrophy  of  the  left  ventricle,  are  several  :  stenosis  and 
regurgitation  at  the  orifice  of  the  aorta;  narrowing  of  the  artery  at  the 
duct  of  Botal  ;  aneurism,  and  compression  of  the  vessel  by  tumors  ; 
atheroma  of  the  arterial  system.  Hypertrophy  of  the  left  auricle  re- 
sults from  obstruction  and  regurgitation  at  the  mitral  orifice,  especially 
narrowing  of  the  orifice.  Similar  causes  produce  similar  effects  on  the 
other  side.  Hypertrophy  of  the  right  ventricle  is  due  to  narrowing  of 
the  pulmonary  orifice,  to  aneurisms,  and  tumors  compressing  the  artery, 
to  chronic  pulmonary  diseases  which  obstruct  the  circulation,  as  em- 
physema, caseous  pneumonia,  fibroid  lung,  large  pleural  accumulations, 
etc.  Hypertrophy  results  from,  or  is  an  attendant  on,  Bright's  disease. 
Various  explanations  have  been  offered  of  the  nature  of  this  relation- 
ship, but  it  is  clear  that,  if  hypertrophy  of  the  muscular  layer  of  the 
arterioles  exists  in  front,  the  heart  has  increased  resistance,  which  re- 
quires additional  effort  to  overcome.  Hypertrophy  is,  so  to  speak,  a 
physiological  result  of  the  changes  in  the  arterial  system  due  to  age  ; 
for  the  calcareous  deposition  in  the  tunics  of  the  aorta  and  of  the  ves- 
sels generally  greatly  increases  the  resistance  of  the  arterial  circuit  by 
diminishing  the  elasticity. 


250  DISEASES   OF   THE   HEART. 

Dilatation. — Simple  dilatation  of  the  heart  occurs  in  delicate  con- 
stitutions, es^^ecially  of  growing  youths,  subjected  to  over-exertion.  This 
has  been  observed  in  armies  on  a  large  scale,  and  by  civil  physicians 
as  well.*  Maclean  f  has  published  observations  on  this  point  made  in 
the  English  service  ;  Seitz  and  others  in  Germany  ;  but  Da  Costa  was 
the  first  to  set  the  subject  in  its  true  light,  by  studies  in  our  hospitals 
during  the  late  rebellion,  and  preceded  all  other  investigators  in  this 
line. 

The  right  ventricle,  being  much  feebler  than  the  left,  is  more  liable 
to  suffer  dilatation.  This  condition  results  from  the  increase  of  pres- 
sure due  to  insufficiency  of  the  semilunar  and  tricuspid  valves,  and 
pulmonary  lesions  w^hich  hinder  the  circulation  in  the  pulmonary  capil- 
laries, such  as  emphysema,  chronic  bronchial  catarrh,  chronic  intersti- 
tial pneumonia,  and  tubercular  and  caseous  infiltration.  On  the  left 
side  the  most  frequent  cause  is  aortic  obstruction  and  insufficiency  ; 
but  obstruction  rather  than  insufficiency  is  more  certain  to  produce  the 
dilatation.  Mitral  insufficiency  leads  to  dilatation  of  the  right  cavities 
by  maintaining  constantly  an  increased  pressure  in  the  pulmonary 
capillaries.  The  cavities  yield  under  normal  pressure  of  the  blood 
when  altered  by  disease.  Pericarditis  and  endocarditis  affect  the  con- 
dition of  the  muscular  tissue,  by  setting  up  a  myocarditis — a  granular 
degeneration.  Myocarditis  arises  under  other  circumstances  also,  and 
the  heart-muscle  is  weakened,  not  by  this  disease  only,  but  by  fatty 
degeneration,  fatty  substitution,  tumors,  etc. 

Pathological  Anatomy. — In  hypertrophy  the  change  may  be  con- 
fined to  one  part,  or  the  whole  organ  may  be  involved.  To  such  enor- 
mous proportions  does  the  heart  attain  sometimes  as  to  be  called  cor 
hovinum — ox's  heart.  The  walls  of  the  left  ventricle  may  increase  to 
an  inch,  an  inch  and  a  half,  or  even  two  inches  in  thickness,  and  the 
walls  of  the  other  cavities  undergo  corresiDonding  development.  The 
shape  of  the  heart  is  altered  by  hypertrophy.  When  there  is  hyper- 
trophy of  the  right  ventricle,  the  heart  is  widened  transversely  and 
the  apex  is  blunted  ;  when  the  left  ventricle  is  enlarged,  the  heart  is 
elongated,  and,  if  its  cavity  is  at  the  same  time  enlarged,  the  septum 
is  pressed  over  into  the  right  ventricle.  When  both  ventricles  are 
enlarged,  the  heart  assumes  a  globular  shape.  The  position  of  the 
hypertrophied  heart  is  more  horizontal ;  if  the  left  ventricle  is  the  seat 
of  the  change,  the  direction  of  the  organ  is  to  the  left  and  downward. 
By  reason  of  an  increase  in  weight  the  heart  in  the  recumbent  posture 
sinks  relatively  lower,  and  hence  the  area  of  absolute  dullness  may 
appear  smaller  ;  in  the  vertical  position  the  heart  descends,  pushing 
the  diaphragm  .before  it,  and  making  the  epigastrium  more  prominent. 

*  Dr.  0.  Frautzel,  "  Ueber  die  Entstehung  von  Hypertrophie  und  Dilatation  der  Herz- 
ventrikel  durch  Kriegsstrapezen,"  Yirchow's  "  Archiv,"  Band  Irii,  S.  215. 
f  "The  British  Medical  Journal,"  February  16,  1867. 


HYPERTROPHY   AND   DILATATION.  251 

In  texture,  the  substance  of  the  heart  is  firmer  than  normal,  and  when 
divided  has  sharp  edges  which  remain  apart.  In  color,  the  tint  is 
brighter  and  fresher  looking  than  in  the  healthy  state.  Subsequently, 
if  fatty  change  begins  in  isolated  patches,  the  reddish-brown  hue  of 
the  muscle  will  be  marked  by  spots  of  a  faintly  yellowish  or  reddish- 
yellow  color.  It  seems  to  be  well  established  that  the  increase  in  the 
muscular  tissue  of  the  heart  is  a  true  hypertrophy,  and  not  a  hyper- 
plasia, that  the  existing  elements  are  increased  in  size,  but  that  no  new 
elements  are  formed.  Dilatation  occurs  chiefly  in  the  auricles,  which 
may  be  so  stretched  that  the  muscular  elements  undergo  fatty  degen- 
eration, are  absorbed  and  disappear,  leaving  the  endo-  and  pericardium 
in  contact,  or  separated  by  some  connective,  tissue  only.  The  size  to 
which  the  auricles  may  be  expanded  is  enormous.  The  right  ventricle 
may  be  much  dilated  and  its  walls  thinned  ;  the  orifices  may  be  much 
enlarged,  the  trabecule  wasted,  and  the  valves  thinned.  The  left  ven- 
tricle is  rarely  dilated  merely,  but  the  walls  are  also  hypertrophied. 

Symptoms — Hypertrophy. — The  signs  and  symptoms  of  cardiac 
disease  are  divisible  into  two  groups — rational^  physical.  The  rational 
signs  are  presumptive,  and  consist  of  the  functional  disturbances  which 
indicate  the  probable  seat  of  the  disease  ;  the  physical  signs  are  de- 
rived from  physical  laws  and  methods,  and  are  positive  in  their  results. 
As  respects  the  rational  symptoms,  the  first  point  to  be  noted  is,  that 
those  vessels  receiving  their  blood-supply  from  an  hypertrophied  ven- 
tricle obtain  more  blood  and  with  greater  force  than  in  the  normal 
condition,  and  hence  the  tension  in  these  vessels  is  higher  ;  whereas, 
the  vessels  on  the  other  side  receive  less  blood  with  diminished  force, 
and  their  tension  is  lower.  When  the  left  ventricle  is  hypertrophied, 
the  tension  is  increased  in  the  aortic  system  and  diminished  in  the  pul- 
monary. The  opposite  condition  obtains  when  the  right  ventricle  is 
enlarged,  for  then  the  pressure  is  greater  relatively  in  the  pulmonary 
system  and  less  in  the  aortic.  When  both  ventricles  have  imdergone 
hypertrophy,  the  tension  is  increased  in  the  aortic  system  and  in  the 
pulmonary  artery.  In  consequence  of  the  increased  distributing  power 
of  the  left  ventricle,  the  blood-cuiTent  is  accelerated  in  the  arterial 
system  and  communicating  capillaries,  and,  as  the  pulmonary  circuit 
has  also  a  higher  tension  and  greater  celerity,  the  blood  received  from 
the  great  venous  trunks  is  quickly  disposed  of,  so  that  the  tension  falls 


Fig.  17. — Hypertrophy. 


in  the  venous  radicles.  The  final  effect  of  pure  hypertrophy  is  an 
acceleration  in  the  whole  round  of  the  circulation.  The  pulse  is  full, 
firm,  and  bounding.     The  ascent  line  of  the  sphygmographic  trace  is 


252  DISEASES   OF   THE   HEART. 

vertical  and  abrupt,  but  the  summit  is  rounded  and  the  descent  oblique, 
unless  there  be  regurgitation  at  the  aortic  orifice.  The  face  is  red  and 
congested  ;  the  nose  bleeds  easily  ;  the  head  feels  full,  and  aches  a 
good  deal,  especially  when  any  strong  muscular  effort  is  made  ;  there 
are  more  or  less  tinnitus  aurium  and  dizziness.  When  the  arterial  walls 
are  weakened  by  atheromatous  degeneration,  cerebral  haemorrhage 
may  be  a  result  of  hypertrophy  of  the  left  ventricle  ;  but  the  way  to 
rupture  is  prepared  by  gradual  yielding  of  the  arterial  tunics,  and 
the  formation  of  minute  aneurismal  dilatations  knovrn  as  "miliary 
aneurisms."  The  strong  beating  in  the  superficial  arteries  is  felt  by 
the  patient,  and  produces  a  disagreeable  roaring  and  beating  in  the 
ears,  especially  when  lying  on  the  left  side.  The  attacks  of  palpitation 
are  frequent,  but  their  severity  is  not  in  proportion  to  the  extent  of  the 
hypertrophy,  for  the  action  may  be  very  tumultuous  when  the  enlarge- 
ment is  slight,  and  vice  versa.  There  are  pretty  constantly  felt  by  the 
patient  a  sense  of  prsecordial  anxiety,  and,  rarely,  attacks  of  pain  ex- 
tending to  the  shoulder  and  arm,  similar  to  angina  pectoris.  A  sense 
of  fullness  in  the  chest,  of  oppression,  and  sometimes  embarrassed 
breathing  are  experienced,  but  the  pulmonary  symptoms  may  be  due 
to  congestion  of  the  bronchial  mucous  membrane,  supplied  as  it  is  by 
the  bronchial  arteries,  and  not  from  the  pulmonary.  When  the  hyper- 
trophy is  confined  to  the  right  ventricle,  no  other  lesion  existing — an 
extremely  rare  condition — the  symptoms  present  will  be  a  sensation  of 
fullness  and  oppression  of  the  chest — possibly  dyspnoea  ;  oedema  and 
haemorrhage  may  occur,  and  the  production  of  interstitial  inflammation 
and  possibly  other  diseases  promoted.  The  foregoing  signs  of  hyper- 
trophy are  presumptive  or  rational ;  the  physical  signs  now  to  be  con- 
sidered establish  the  seat  and  character  of  the  lesion.  On  ijisj^ection 
there  is  to  be  observed  a  prominence  of  the  chest,  greatest  at  the  junc- 
tion of  the  fourth  and  fifth  ribs  with  the  sternum.  This  has  been  denied; 
but,  that  it  is  often  encountered  in  hypertrophy  occurring  in  young 
subjects,  the  author's  experience  entitles  him  to  aflirm.  When  hyper- 
trophy occurs  later  in  life,  the  ribs  having  become  rigid,  no  elevation 
of  the  chest-wall  can  be  effected,  how  powerful  soever  may  be  the 
impulse  of  the  heart.  As  in  hypertrophy,  the  position  of  the  heart  is 
more  horizontal  and  depressed  to  the  left,  on  2yoJpation,  the  apical  im- 
pulse is  felt  near  to  the  axillary  line,  and  one,  two,  and  possibly  three 
intercostal  spaces  lower  down,  and  it  is  stronger  and  more  widely  dif- 
fused. The  force  of  the  impulse  is  sufficient  to  raise  the  hand  when 
placed  on  the  cardiac  region,  or  the  head  when  applied  in  auscultation, 
and  the  whole  left  thorax  may  be  felt  lifted  up  and  carried  toward  the 
left.  This  is  entitled  the  heaving  impulse,  and  is  very  characteristic 
of  extreme  hypertrophy.  Instead  of  the  impulse  having  a  heaving 
character,  sometimes  it  makes  the  impression  of  a  sudden  jar  which  is 
immediately  arrested.    In  hypertrophy  of  the  right  ventricle  the  heav- 


HYPERTROPHY   AND   DILATATION.  253 

ing  impulse  is  felt  at  the  end  of  the  sternum,  especially  its  right  border, 
and  in  the  epigastrium.  In  the  third  and  fourth  intercostal  spaces  to 
the  right  of  the  sternum,  the  impulsion  of  the  hypertrophied  auricles 
may  sometimes  be  felt.  On  percussion,  the  area  of  praecordial  dullness 
can  be  demonstrated.  The  absolute  or  superficial  dullness  is  that  de- 
rived by  percussion  over  that  portion  of  the  heart  uncovered  by  the 
lung — a  triangular  space  ;  the  relative  or  deep  dullness  is  that  obtained 
by  sti'ong  percussion  over  that  portion  of  the  heart  covered  by  the 
lung.  The  dull  space  extends  from  a  point  internal  to  the  upper  border 
of  the  second  rib  at  its  junction  with  the  sternum,  obliquely  downward 
to  the  left  to  the  apex-beat,  thence  transversely  to  the  right  border  of 
the  sternum.  This  is  an  irregularly  triangular  or  ovoidal  space  which 
returns,  on  percussion,  the  forms  of  dullness  mentioned  above.  The 
area  of  absolute  dullness  is  increased  by  hypertrophy  of  the  heart,  if 
the  patient  is  percussed  when  erect  and  inclined  slightly  forward.  The 
relative  dullness  is  increased  more  when  the  patient  is  recumbent,  by 
the  heart  sinking  backward.  In  hypertrophy  of  the  left  ventricle,  the 
dullness  is  parallel  to  the  long  axis  of  the  heart ;  in  hypertrophy  of 
the  right,  the  dullness  is  over  the  lower  extremity  of  the  sternum. 

When  pure  hypertrophy  is  the  condition  under  examination,  aus- 
cultation furnishes  no  important  information.  The  sounds  of  the  heart 
are  somewhat  aifected  in  their  timbre.  In  hypertrophy  of  the  left 
ventricle,  the  first  or  ventricular  sound  has  a  rather  metallic  quality, 
and  the  second  sound  is  strongly  "  accentuated "  ;  in  hypertrophy  of 
the  right,  the  same  facts  exist,  but  the  sounds  are  less  intense.  At  the 
apex,  a  peculiar  metallic  "  click  "  is  sometimes  heard,  and  is  doubtless 
due  to  the  vibration  in  the  chest-well,  produced  by  a  very  strong  im- 
pulse.    It  is  much  louder  when  the  stomach  is  distended  with  gas. 

Dilatation. — When  dilatation  occurs  in  any  of  its  forms,  the  propul- 
sive power  of  the  heart  is  diminished  ;  less  so,  however,  in  active  dila- 
tation. The  result  of  this  is  a  condition  of  ischaemia  in  one  set  of  ves- 
sels, and  of  stasis  in  the  other  system.  Thus,  when  the  left  ventricle 
is  dilated,  there  is  a  lowering  of  tension  in  the  aortic  system,  and  an 
increase  of  pressure  and  abnormal  fullness  of  the  pulmonary;  when  the 
right  ventricle  is  dilated,  there  are  diminution  of  tension,  and  ischae- 
mia of  the  pulmonary  artery,  and  elevation  of  pressure  with  stasis  in 
the  peripheral  venous  system.  The  ultimate  effects  of  the  disturbance 
in  the  vascular  system  are  the  same  when  one  ventricle  is  dilated  as  if 
both  were,  for,  taking  as  an  example  the  most  common  dilatation,  that 
of  the  right  side  of  the  heart,  the  stasis  in  the  peripheral  veins  extends 
to  the  capillaries,  to  the  arteries,  thence  to  the  left  side,  and  vice  versa. 
When,  however,  dilatation  of  the  right  ventricle  coincides  with  hyper- 
trophy of  the  left,  the  excess  in  power  of  the  one  compensates  for  the 
deficiency  in  the  contractile  energy  of  the  other.  The  results  of  dila- 
tation of  all  the  cavities  are  these  :  the  vessels  receiving  blood  from 


254  DISEASES   OF   THE  HEAET. 

the  heart — efferent  vessels — are  in  a  condition  of  ischsemia,  or  dimin- 
ished blood-supply,  while  the  vessels  conveying  the  blood  to  the  heart 
— afferent  vessels — are  constantly  abnormally  full,  or  in  a  condition  of 
hypersemia  and  exaggerated  tension.  When  the  right  heart  is  dilated, 
there  are  ischgemia  of  the  pulmonary  vessels,  producing  habitual  dys- 
pnoea, insufficient  haematosis  or  aeration  of  the  blood,  and  stasis  in  the 
general  venous  system.  The  peripheral  veins  are  turgid  with  blood, 
there  is  cyanosis  from  deficient  aeration,  and  a  constant  hyperaemia 
of  the  liver,  spleen,  kidneys,  and  intestinal  canal.  Increase  of  pres- 
sure in  the  renal  veins  causes  albuminuria  ;  in  the  hepatic  veins,  jaun- 
dice and  ascites  ;  in  the  veins  of  the  extremities,  cedema  and  general 
dropsy,  and  thrombosis.  The  rational  symptoms  of  these  functional 
disturbances  are,  palpitations  of  the  heart  ;  frequency  and  irregu- 
larity of  the  pulse  ;  deficiency  in  the  arterial  blood-supply  to  the 
brain,  and  manifest  in  vertigo,  ringing  in  the  ears,  attacks  of  faint- 
ness  or  actual  syncope,  etc.  ;  deficiency  in  the  blood  going  to  the 
lungs,  and  causing  cough,  dyspnoea,  etc.  The  composition  of  the 
blood  is  impaired  by  the  excess  of  carbonic  acid  ;  the  lessening  of  the 
oxidation  processes  diminishes  the  production  of  heat,  and  hence  the 
general  temperature  is  low  ;  the  vessels  themselves,  the  heart,  and  the 
tissues,  undergo  nutritive  changes  in  consequence  of  insufficient  energy 
in  the  process  of  tissue  metamorphosis.  A  cachectic  state,  with  low- 
ered vitality  of  the  tissues,  so  that  they  ulcerate  under  the  least  irri- 
tation, is  the  necessary  outcome  of  these  changes.  There  is  not  only 
a  lowered  state  of  the  assimilative  functions,  but  elimination  is  im- 
perfectly carried  on,  and  excrementitious  materials  are  retained  in 
the  blood — carbonic  acid  and  urea — causing  hallucinations,  delirium, 
eclampsia,  coma,  etc.  The  ill  results  of  these  nutritive  alterations  are 
also  exhibited  in  increased  damage  to  the  heart-muscle,  and  conse- 
quently an  exaggeration  of  the  mechanical  effects  of  the  dilatation. 
Inspection  furnishes  no  information  of  value,  except,  when  dilatation 
of  the  right  cavities  render  the  valves  incompetent,  a  venous  pulse 
will  be  visible  in  the  neck.  On  palpation,  the  area  of  cardiac  impul- 
sion is  as  wide  as  in  hypertrophy,  but  the  apical  impulse  is  feeble,  and 
may  not  be  felt  when  the  patient  is  recumbent.  When  there  is  hyper- 
trophy of  the  right  heart  to  compensate  for  dilatation  of  the  left  cavi- 
ties, the  apical  impulse  will  be  feeble,  while  the  pulse  of  the  right  cavi- 
ties at  the  border  of  the  lower  sternum  will  be  comparatively  strong. 
On  percussion  the  extent  of  dullness  is  made  out  as  in  hypertrophy. 
On  auscultation,  the  sounds  are  feeble,  as  a  rule  ;  on  the  other  hand, 
they  may  have  a  more  clear  and  resonant  quality.  A  soft-blowing 
murmur  sometimes  takes  the  place  of  the  first  sound.  This  murmur 
is  situated  in  the  mitral  and  tricuspid  areas,  and  is  due  to  the  insuf- 
ficiency of  the  valves  to  close  the  auriculo-ventricular  orifices. 

Diagnosis. — Hypertrophy  is  to  be  distinguished  from  dilatation  of 


HYPERTROPHY  AND   DILATATION.  255 

the  heart,  from  pericardial  effusions,  tumors  of  the  mediastinum,  etc. 
The  force  of  the  impulse,  the  accentuation  of  the  second  sound,  and  the 
state  of  the  systemic  circulation,  enable  the  differentiation  to  be  made 
from  dilatation,  and  also  from  effusion  ;  besides,  in  the  latter,  the  dull- 
ness has  been  preceded  by  a  friction-sound,  and,  when  the  effusion 
comes  on,  the  heart-sounds  weaken  and  disappear.  The  seat  of  the 
dilatation  is  determined  chiefly  by  the  position  of  the  dullness.  Hyper- 
trophy and  dilatation  are  differentiated  from  tumors  in  the  mediasti- 
num, by  the  displacement  of  the  heart  occasioned  by  the  latter,  and  by 
the  persistence  of  the  normal  heart-sounds.  The  pressure  of  a  tumor 
on  the  great  vessels  and  impoi'tant  nerves  introduces  into  the  symp- 
tomatology of  the  case  new  symptoms  quite  foreign  to  either  hyper- 
trophy or  dilatation.  From  pleui'itic  effusion  in  the  neighborhood, 
retained  by  adhesions — the  so-called  encapsulated — the  dullness  due  to 
hypertrophy  or  dilatation  may  be  difficult  to  separate,  but  effusions 
displace  the  heart  without  altering  the  character  of  its  impulse  and  its. 
murmurs  ;  when  the  pleural  effusions  are  unconfined,  the  ready  dis- 
tinction consists  in  the  change  of  the  position  of  the  patient,  shifting 
the  dullness. 

Course,  Duration,  and  Termination. — The  course  of  these  affections 
is  chronic,  but  hypertrophy  continues  much  longer  than  dilatation. 
Hypertrophy,  uncomplicated,  exists  unchanged  for  many  years,  and  is 
important  rather  on  account  of  the  complications  which  may  grow  out 
of  it  than  of  itself,  yet  changes  in  the  heart-substance  and  in  the  ves- 
sels must  eventually  result.  Over-supply  of  blood  to  organs  leads  to 
nutritive  alterations  in  them.  Rupture  of  vessels  may  take  place,  but 
disease  of  the  arterial  tunics  is  necessary  also  ;  hence  the  importance 
of  hypertrophy  of  the  heart  as  a  factor  in  cerebral  and  in  pulmonary 
hgemorrhage.  Dilatation  of  the  cavities  is  much  more  rapid  in  its 
course  and  important  in  its  results  than  hypertroj)hy,  but  simple  and 
passive  dilatations  are  more  serious  than  the  active  form.  The  heart 
is  much  weaker,  its  tissues  become  diseased,  and  death  may  be  sudden 
by  pai'alysis  or  by  ruj^ture,  or  in  attacks  similar  to  angina  pectoris. 
The  stasis  in  the  circulation,  the  pulmonary,  hepatic,  and  renal  trou- 
bles, and  the  general  dropsy  which  result  from  dilatation,  are  the 
usual  sequelae,  and  death  ultimately  occurs  from  the  combined  effect 
of  these  disturbances. 

Prognosis. — The  prognosis  is  necessarily  grave,  but  it  should  always 
be  guarded.  Simple  hypertrophy  may  exist  for  years,  without  any 
apparent  interference  with  function.  In  dilatation,  the  hope  of  any 
lengthened  period  of  freedom  from  ill  results  can  not  be  encouraged. 
When  dropsy  appears,  it  becomes  a  question  of  the  physical  endur- 
ance largely,  for  death  can  not,  then,  long  be  delayed. 

Treatment — Hypertrophy. — When  hypertrophy  is  compensatory  or 
compensated,  there  is  no  need  of  therapeutical   measures.      It  may, 


256  DISEASES   OF   THE   HEART. 

however,  be  necessary  to  combat  the  hypertrophy,  or  its  results  in 
the  organism  at  large,  if  the  force  of  the  heai't  and  the  pressure  in  the 
vascular  system  are  so  great  as  to  threaten  serious  consequences.  The 
most  direct  method  is  the  abstraction  of  blood,  either  by  venesection 
or  by  leeches,  and  this  is  allowable  in  vigorous  subjects.  Purgatives 
lower  the  blood-pressure,  especially  the  saline  purgatives,  which  draw 
off  by  the  intestinal  mucous  membrane  more  or  less  fluid.  They  are 
much  less  objectionable  than  bloodletting,  are  more  easily  handled, 
and  are  more  permanent  in  results.  Next  to  saline  purgatives  in  effi- 
ciency is  the  tincture  of  aconite-root.  Tincture  of  veratrum  viride  is 
more  powerful,  but  less  easily  managed,  for  its  effects  are  quickly  pro- 
duced and  not  easily  confined  within  the  prescribed  limits.  The  action 
of  the  heart  may  be  readily  maintained  by  aconite  at  a  uniform  rate, 
which  need  not  be  lower  than  seventy  beats  of  the  pulse  per  minute. 
The  abnormal  fullness  of  the  vascular  system  may  also  be  lessened  by 
reducing  the  gross  amount  of  aliment  taken  in  the  twenty-four  hours. 
This  method  will  be  all  the  more  effective  if  the  rate  of  waste  is  en- 
couraged by  the  use  of  potassa  salts,  which  also  increase  the  discharge 
of  the  products  of  waste  by  the  kidneys. 

The  treatment  of  dilatation  must  pursue  the  opposite  direction. 
The  general  nutrition  must  be  maintained  at  the  highest  point,  to  pro- 
mote the  nutrition  of  the  cardiac  muscle.  A  generous  diet,  moderate 
exercise  in  the  open  air,  the  inhalation  of  oxygen,  are  important  agen- 
cies to  accomplish  the  objects  just  mentioned.  Bitters  to  increase  the 
appetite  and  iron  to  improve  the  quality  of  the  blood  are  strongly  in- 
dicated. To  tone  up  the  heart  and  raise  the  tension  of  the  vascular 
system,  there  is  no  remedy  so  efficient  as  digitalis.  It  should  be  given 
with  quinia,  which  is  also  an  excellent  heart-tonic.  The  most  remark- 
able effects  attend  the  use  of  minute  doses  of  morphia  hypodermati- 
cally  in  these  cases.  When  there  is  extreme  dyspnoea,  the  heart  very 
feeble,  the  fluid  everywhere  gaining,  the  effect  of  the  injection  is 
almost  magical.  It  sometimes  happens  that  the  symptoms  are  too 
urgent  to  await  the  slow  action  of  digitalis,  or  it  may  be  the  stomach 
will  not  tolerate  the  digitalis  in  any  form,  then  the  injection  is  most 
opportune — the  patient  is  relieved  by  it — time  is  gained  for  the  action 
of  digitalis,  or  the  stomach  will  bear  it  better. 


ENDOCARDITIS  — INFLAMMATION     OF     THE     ENDOCARDIUM— 
PLASTIC    ENDOCARDITIS. 

Definition. — The  endocardium  is  a  delicate  serous  membrane,  lining 
the  cavities  of  the  heart  and  forming  its  valves.  The  acute  inflam- 
mation occurs  in  two  distinct  forms,  which  differ  so  widely  as  to 
require  separate  consideration  :  plastic,  or  simple  exudative  inflam- 
mation ;  ulcerous,  or  diphtheritic  inflammation.      The  plastic  form  is 


ENDOCARDITIS.  25T 

either  acute  or  chronic,  but  these  differ  merely  in  degree  and  rate  of 
progress. 

Causes. — Primary  or  idiopathic  endocarditis,  except  in  the  ulcerous 
form,  is  extremely  rare.  Plastic  endocarditis  is  usually  a  secondary 
affection  :  secondary  to  pleuritis,  pneumonia,  pericarditis,  myocarditis, 
etc.,  but,  very  much  more  frequently,  secondary  to  acute  rheumatism. 
The  relative  frequency  of  endocardial  inflammation  in  acute  rheuma- 
tism, is  differently  stated  by  different  observers.  According  to  some, 
one  half,  others  one  third,  of  the  cases  are  complicated  by  endocarditis, 
but  the  real  number  is,  no  doubt,  lower  than  one  third.  The  source  of 
error  is  the  occurrence  of  a  soft-blowing  murmur  in  cases  of  rheuma- 
tism, due  not  to  inflammation  of  the  endocardium  but  to  the  condition 
of  the  blood.  The  more  severe  the  type  of  rheumatic  fever  the  greater 
the  danger  of  cardiac  complications,  but  there  are  numerous  exceptions 
to  this  rule.  The  pericardial  and  endocardial  inflammation  may  pre- 
cede the  joint-troubles. 

Pathological  Anatomy.^The  initial  lesion  is  hypertemia,  which  in- 
volves the  sub-serous  connective  tissue  as  well  as  the  membrane  itself. 
The  stasis  in  the  vessels  induces  rupture  of  the  capillaries,  here  and 
there,  and  minute  extravasations  are  thus  formed.  Migration  of  white 
corpuscles,  exudation  of  fibrinogenous  and  germinal  matter,  now  takes 
place  into  the  affected  membrane,  and  the  cells  of  the  endothelium  be- 
come cloudy,  loosen,  and  undergo  proliferation.  The  membrane,  which 
in  health  is  thin,  transparent,  and  glistening,  becomes,  as  a  result  of  these 
changes,  rough,  opaque,  and  thickened.  The  roughness  of  the  mem- 
brane is  due,  further,  to  the  formation  of  lamellif orm  or  conical  vegeta- 
tions, the  product  of  the  activity  in  cell  proliferation  at  particular  j)arts, 
or,  according  to  Rindfleisch,  they  are  composed  of  an  homogeneous 
fibrinous  exudation  from  the  vessels.  K  the  changes  in  the  structure 
of  the  membrane  do  not  go  beyond  this  point,  it  is  probable  that  com- 
plete restitution  may  occur.  Proceeding  from  this  point  the  inflam- 
mation may  take  the  plastic  or  the  ulcerous  form.  We  are  now  con- 
cerned with  the  former  only.  The  exudation  on  the  auriculo-ventricu- 
lar  valves  (mitral)  is  found  chiefly  at  the  free  border,  where  the  ten- 
dons are  inserted  ;  on  the  semi-lunar  valves  (aortic)*  on  the  lateral 
border  where  the  segments  come  in  contact,  yet  the  corpora  arantii 
may  also  be  the  seat  of  abundant  exudation.  The  vegetations  pro- 
jecting from  the  surface  of  the  membrane  entangle  masses  of  fibrin 
whipped  out  of  the  blood,  which  may  project  from  the  valves,  swing- 
ing to  and  fro  like  a  polypoid  excrescence.  The  chordae  tendinse  may 
be  affected  in  a  manner  similar  to  the  valves.  Softened  by  the  inflam- 
matory process,  the  chordae  may  give  way,  permitting  a  segment  to 
become  adherent  to  a  neighboring  one.  Adhesion  of  the  semi-lunar 
valves  may  occur  at  the  side  where  they  are  in  contact.  The  adhe- 
sions undergo   organization,  and  thus  the  most  serious  changes  are 


258  DISEASES   OF   THE   HEART. 

wrought  in  the  structure  and  functions  of  the  valves.  Also,  large 
masses  of  fibrin  may  be  entangled  in  them,  and  they  may  be  the  cause 
of  thrombotic  deposits  around  them.  When  the  inflammatory  pro- 
cess passes  to  the  chronic  stage,  characteristic  changes  take  place  in 
the  exudation  :  it  loses  some  part  of  its  water,  solidifies,  and  subse- 
quently contracts.  The  connective  tissue  undergoes  hyperplasia,  espe- 
cially the  connective  tissue  of  the  borders  of  the  valves,  but  the  mem- 
brane, generally  of  the  valves,  may  be  affected  by  the  same  change. 
As  a  result  of  the  tendency  of  the  new  material  to  contract,  the  valves 
become  much  deformed,  thick,  and  inflexible,  and,  of  course,  their 
functions  are  correspondingly  impaired.  Calcareous  changes  occur  in 
the  deposits,  and  fatty  degeneration  also  takes  place.  Patches  of  soft- 
ening also  occur  in  the  valves,  the  membrane  yields,  and  pouches  or 
aneurisms  form,  which  ultimately  give  way,  and  thus  a  valve  is  per- 
forated. This  process,  occurring  at  various  points,  imparts  to  the 
valve  a  sieve-like  appearance.  Vegetations  detached,  or  bits  of  ad- 
herent fibrin  cast  off,  constitute  emboli,  which,  entering  the  blood-cur- 
rent, will  be  deposited  in  distant  parts — on  the  left  side  of  the  brain, 
in  the  kidneys,  spleen,  etc.  The  orifices  of  the  valves  undergo  similar 
changes.  The  connective-tissue  transformations  take  place,  and  hence 
rigidity,  deformities,  and  contraction  result. 

Symptoms. — When  endocarditis  is  idiopathic,  which  is  very  rare, 
its  onset  is  marked  by  the  usual  symptoms  of  an  acute  febrile  or  in- 
flammatory affection.  There  is  a  chill,  followed  by  fever,  a  coated 
tongue,  anorexia,  nausea,  sometimes  vomiting,  and  general  malaise. 
As  it  occurs  in  the  course  of  another  disease,  the  additional  disturbance 
induced  by  it  may  altogether  escape  recognition,  and  it  is  only  by  per- 
sistent watchfulness,  under  such  circumstances,  that  it  is  discovered. 
This  is  true  of  its  onset  in  rheumatism,  Bright's  disease,  the  eruptive 
fevers,  etc.  On  the  other  hand,  the  commencement  of  endocarditis 
may  be  manifest  by  very  obvious  signs.  For  example,  if  during  the 
course  of  acute  rheumatism  endocarditis  comes  on,  there  will  occur  an 
increase  in  the  temperature,  the  thermometer  rising  a  degree  or  two, 
the  pulse  will  become  more  rapid,  and  the  general  condition  less  favor- 
able, than  before  the  complication  arose.  The  fever  does  not  pursue  a 
special  type,  and  the  pulse  exhibits  no  characteristic  quality.  The 
other  rational  symptoms  are  equally  indefinite.  There  may  or  may 
not  be  some  uneasiness  in  the  region  of  the  heart,  some  prsecordial 
opj)ression,  and  some  palpitation.  There  may  occur,  also,  increased 
impulsion  of  the  heart,  more  rapid  and  tumultuous  beating  of  the  ca- 
rotids, headache,  noises  in  the  ears,  some  dyspnoea,  etc.  After  a  time 
the  action  of  the  heart  becomes  less  energetic,  the  strength  of  the 
pulse  declines,  the  function  of  hgematosis  is  impaired,  and  hence  the 
functions  generally,  especially  the  cei-ebral,  are  less  energetically  per- 
formed.    The  physical  signs  are  much  more  distinctive  than  the  ra- 


EXDOCAKDITIS.  259 

tional ;  tlie  changes  in  the  valves  and  at  the  orifices  necessarily  modify 
the  character  of  the  murmurs,  or  add  new  sounds.  The  period  and 
position  of  the  murmur  are  determined  by  the  valve  affected  and  by 
the  time,  in  the  cardiac  revolution,  when  the  blood-current  passes  the 
affected  orifice.  In  mitral  insufiiciency  a  hridt  or  murmur  is  audible 
with  the  first  sound  (systolic)  at  the  apex,  and  with  the  second  sound 
(diastolic),  or  after  it  (presystolic),  if  there  is  obstruction  at  the  mitral 
orifice.  In  aortic  obstruction  the  murmur  is  audible  with  the  first 
sound  (systolic)  at  the  base,  and  with  the  second  sound  (diastolic)  if 
the  aortic  valves  are  insufficient.  If  the  lesions  occur  on  the  opposite 
or  right  side  of  the  heart,  which  is  very  rare,  the  same  rules  obtain,  but 
the  position  at  which  the  sounds  are  heard  is  different.  To  hear  the 
sounds  at  the  right  auriculo-ventricular  orifice,  the  ear  must  be  placed 
over  the  ensiform  appendix,  and,  for  the  pulmonary  valves,  at  the  junc- 
tion of  the  third  right  rib  with  the  sternum.  Percussion  affords  but 
little  information.  If  there  be  aortic  obstruction,  some  distention  of 
the  heart  is  occasioned,  which  increases  the  area  of  dullness  in  the  ver- 
tical direction  ;  if  mitral  obstruction,  the  right  cavities  will  be  some- 
what dilated  and  the  dullness  increased  in  the  transverse  direction. 
The  facts  may  be  formulated  as  follows  :  In  acute  endocarditis  the 
same  physical  signs  characteristic  of  chronic  valvular  diseases  of  the 
heart  occur  suddenly  ;  and,  further,  the  sudden  development  of  the 
symptoms  of  mitral  insufficiency  is  the  most  characteristic  sign  of 
acute  endocarditis  (Jaccoud).  Obstruction  or  regurgitation  at  the 
mitral  orifice  increases  the  pressure  of  the  blood  in  the  pulmonary  ar- 
tery, and  hence  a  physical  sign  of  this  condition  is  accentuation  of  the 
pulmonary  second  sound.  More  or  less  congestion  of  the  lungs  and  sta- 
sis in  the  venous  system  are  necessary  consequences  of  mitral  disease. 

Course,  Duration,  and  Termination. — The  course  of  acute  plastic 
endocarditis  is  necessarily  brief.  The  patient  either  partially  recovers 
by  the  disease  assuming  the  subacute  and  chronic  phase,  or  he  dies 
from  the  immediate  consequences  and  complications.  When  the  case 
passes  from  acute  to  chronic,  the  fever  ceases,  compensation  takes  place, 
by  which  the  disorders  of  circulation  are  obviated  for  a  time,  yet  the 
physical  signs  of  valvular  mischief  continue.  Death  may  result  from 
a  gradual  weakening,  terminating  in  paralysis  of  the  heart,  or  heart- 
clot  may  form,  or  a  cerebral  embolism  occur.  Pericarditis,  myocar- 
ditis, and  pneumonia,  may  also  intervene  and  take  life.  That  a  cure 
of  actual  lesions  may  happen  is  admitted,  but  the  examples  of  such  a 
fortunate  termination  are  extremely  infrequent.  The  duration  of  the 
acute  attack  is  short ;  of  the  subacute  and  chronic  form,  indefinite. 

Diagnosis. — The  differentiation  consists  in  the  application  of  the 
physical  signs.  It  should  not  be  forgotten  that  a  murmur  exists  of  a 
soft-blowing  character,  not  due  to  valvular  lesion,  and  which  disap- 
pears on  the  subsidence  of  the  acute  symptoms. 


260  DISEASES   OF  THE   HEART. 

Prognosis. — The  acute  form  is  not  very  dangerous  to  life,  and  hence 
a  favorable  prognosis  may  be  expressed.  As  regards  tlie  ultimate  re- 
sults of  valvular  lesions,  tbe  prognosis  is  grave. 

Treatment. — The  character  of  the  associated  malady  and  the  con- 
dition of  the  patient  must  enter  largely  into  the  consideration  of  reme- 
dies. As  it  is  a  fundamental  principle  to  keep  the  suffering  organ 
quiet,  remedies  capable  of  effecting  this  are  very  important — these 
are,  ice  and  digitalis.  An  ice-bag  should  be  applied  to  the  precordial 
region,  and  a  tablespoonf ul  of  infusion  of  digitalis  given  every  four 
hours.  Flying-blisters  should  be  applied  to  the  axillary  region.  In 
the  incipiency,  before  much  damage  has  been  done,  there  can  be  no 
doubt  of  the  great  efficacy  of  the  hypodermatic  injection  of  morphia, 
or  the  internal  administration  of  morphia  and  quinine — one  quarter 
grain  of  morphia  and  ten  grains  of  quinia  every  four  hours  until  three 
or  four  doses  are  taken.  When  considerable  exudation  has  occurred, 
besides  the  remedies  to  quiet  the  heart,  ammonia  should  be  given  freely, 
with  the  view  to  exert  a  solvent  action.  The  best  form  for  adminis- 
tration is  the  carbonate  (ten  grains)  in  the  solution  of  the  acetate 
(half  an  ounce)  every  four  hours,  or  half  the  quantity  every  two  hours. 
If  there  be  much  depression  in  the  progress  of  the  case,  quinia  and 
digitalis  should  be  prescribed  in  combination. 


ULCERATIVE  ENDOCARDITIS— DIPHTHERITIC  ENDOCARDITIS. 

Definition.— This  is  a  peculiar  form  of  disease,  in  which  ulcerations 
and  dii^htheritic  exudations,  with  colonies  of  micrococci,  develop  in 
the  endocardium,  followed  by  septic  infection  of  the  blood  and  mul- 
tiple embolisms. 

Causes. — A  peculiar  state  or  type  of  constitution  seems  necessary 
to  develop  this  disease.  It  occurs  during  the  course  of  some  cases  of 
a'cute  rheumatism,  of  puerperal  fever,  of  diphtheria,  etc.,  and  now  and 
then  this  process  attacks  the  valves  in  cases  of  chronic  plastic  endo- 
carditis, the  new  material  undergoing  rapid  and  destructive  ulceration. 
This  disease  occurs  from  puberty  to  forty  years.  A  depressed  condi- 
tion of  the  vital  forces,  due  to  bad  hygienic  influences,  seems  to  be 
very  influential  in  determining  the  occurrence  of  this  disease  in  youths. 
The  close  analogy  between  the  diphtheritic  process  and  this  ulcerous 
disease  of  the  left  heart  and  the  frequent  coincidence  of  the  two  affec- 
tions render  it  highly  probable  that  the  diphtheritic  poison  is  the 
chief  if  not  the  only  factor  in  its  causation. 

Pathological  Anatomy. — The  initial  lesions  are  the  same  as  those 
described  under  the  head  of  plastic  endocarditis.  The  lesions  are 
chiefly  on  the  left  side  of  the  heart,  and  attack  by  preference  the 
anterior  flap  of  the  mitral  and  the  semi-lunar  valves  of  the  aorta  ;  next 
the  walls  of  the  appendages  to  the  left  auricle,  and,  lastly,  the  walls  of 


ENDOCARDITIS.  261 

the  ventricle.  Occasionally  the  same  morbid  process  occurs  on  the 
right  side,  and,  in  one  reported  case,  on  the  tricuspid  only,*  and  its 
chordte  tendinse,  which  were  destroyed.  After  the  initial  changes 
already  described,  the  nuclei  of  the  connective  tissue  undergo  rapid 
proliferation  and  form  granulations  of  the  surface ;  fibrinous  depos- 
its take  place,  and  the  whole  forms  a  "  felt-like "  mass,  intimately 
connected  with  the  tissues  beneath.  A  process  of  softening  then 
begins  in  the  interior  of  these  masses ;  they  crumble  and  fall  away, 
and  leave  a  ragged,  irregular  ulcer,  which  is  the  seat  of  fresh  fibrin- 
ous deposits.  Perforation  of  the  valve  may  ultimately  take  place, 
and  the  margins  of  the  perforation  are  rough,  ragged,  and  ulcer- 
ated ;  and  they  are  surrounded  by  granulations  having  the  same  struc- 
ture as  those  which  have  already  ulcerated.  A  distinctive  peculiarity 
of  this  process  is  the  presence  early  in  the  course  of  formation  of 
the  granulations,  and  in  the  midst  of  the  proliferating  connective- 
tissue  corpuscles,  of  a  finely  granular  material,  the  particles  having 
various  shapes,  strongly  refractive  of  light,  and  resisting  the  action  of 
acids  and  alkalies.  These  granules,  as  Virchow  was  the  first  to  point 
out,  are  micrococci,  and  the  granular  masses  are  colonies  of  micro- 
cocci. The  losses  of  substance  by  thinning  the  valves  lead  to  the  for- 
mation of  the  so-called  valvular  aneurisms,  and  coagula  forming  in 
these  are  thrown  off  with  patches  of  diseased  tissue,  when  the  aneurism 
gives  way.  Ulceration  of  the  septum,  induced  in  the  same  way,  leads 
to  communication  between  the  cavities.  The  particles  of  ulcerating 
tissue,  of  fibrin  and  blood-clot,  and  the  little  masses  of  micrococci  colo- 
nies thrown  off  into  the  blood-current,  form  multiple  embolisms.  Two 
results  follow  :  either  there  is  merely  mechanical  obstruction  of  vessels, 
or  an  infective  process  is  set  up  the  same  as  that  of  the  original  disease. 
The  spleen,  kidneys,  and  brain,  are  the  organs  in  which  these  de- 
posits take  place  from  the  left  side  of  the  heart.  When  the  disease  is 
in  the  right  side  of  the  heart,  the  emboli  are  swept  into  the  lungs. f  As 
these  organs  contain  the  "  terminal  arteries  "  of  Cohnheim,  there  will 
occur  hsemorrhagic  infarctions  and  ichorous  suppuration.  All  the 
organs  of  the  body  may,  indeed,  be  the  seat  of  abscesses  for  embolic 
deposits.  The  distribution  of  infective  materials — specific  micrococci 
— sets  up  a  general  infection  of  the  blood.  Wherever  the  micrococci 
are  deposited  they  undergo  rapid  multiplication,  and  initiate  the  same 
morbid  action  as  at  the  original  source  of  infection.  Numerous  are 
the  alterations  occurring  in  various  organs  in  ulcerative  endocarditis. 
The  spleen  is  very  much  enlarged,  whether  the  seat  of  infarctions  or 
not ;  in  the  kidneys  are  abscess  formations,  and  the  afferent  vessels 
are  blocked  with  colonies  of  migrating  micrococci ;  in  the  brain  there 

*  T.  Whipham,  M.  B.,  "  Transactions  of  the  Pathological  Society,"  vol.  xxii,  p.  118. 
f  C.  J.  Eberth,  Virchow's  "  Archiv,"  Band  Ivii,  "  Ueber  diphtherische  Endocarditis." 


262  DISEASES   OF   THE   HEART. 

are  extravasations,  especially  of  the  meninges  ;  in  the  lungs,  abscesses 
from  emboli ;  in  the  heart,  myocarditis  and  pericarditis  ;  and  in  the 
small  intestine,  swelling  of  the  patches  of  Peyer  and  solitary  glands, 
and  ulcerations  which  differ  from  those  of  typhoid,  in  that  they  are 
not  confined  to  the  lower  extremity  of  the  ilium,  are  not  opposite  the 
insertion  of  the  mesentery,  and  are  not  limited  to  the  glands.* 

Symptoms. — Cases  of  ulcerative  endocarditis  differ  much  in  their 
objective  symptoms,  but  they  may  be  referred  to  two  types  :  typhoid; 
pyaemic.  In  both,  the  cardiac  symptoms  are  quite  masked  by  the  pre- 
ponderating importance  of  the  systemic  state,  and  hence  cases  of  pri- 
mary endocarditis  are  apt  to  be  overlooked.  When  there  is  an  attack 
of  rheumatism  going  on,  suspicion  of  cardiac  mischief  will  of  course  be 
excited  by  the  sudden  occurrence  of  a  violent  chill  which  inaugurates 
both  forms.  In  the  typhoid  form  succeeding  the  chill  there  is  con- 
siderable fever,  the  range  of  temperature  being  rather  of  the  remittent 
type  ;  headache,  vertigo,  and  extreme  prostration,  and  sometimes  a 
sense  of  prsecordial  oppression,  are  then  experienced  ;  the  tongue  is  dry 
and  brownish  ;  there  are  nausea  and  vomiting,  and  the  bowels  are  con- 
stipated, or  diarrhoea  is  present.  The  prostration  gains  rapidly,  and  by 
the  fourth  day  a  condition  of  depression  is  reached  comparable  to  the 
second  week  of  typhoid.  The  resemblance  to  typhoid  is  all  the  greater, 
since  the  abdomen  is  swollen  and  tympanitic  and  the  spleen  is  enlarged. 
Delirium  (irritation)  soon  comes  on,  to  be  replaced  in  a  few  days  by 
stupor  and  coma  (depression),  A  severe  diarrhoea  now  succeeds  to 
constipation,  if  that  condition  has  existed  before,  and  the  perplexity 
of  the  case  may  be  enhanced  by  rose-spots  and  petechias  appearing  on 
the  abdomen.  Presently,  the  patient  lying  in  a  comatose  state,  the 
stools  and  urine  are  passed  involuntarily.  The  urine  has  a  smoky  ap- 
pearance, and  contains  more  or  less  blood,  and  albumen  is  present. 
There  is  usually  some  bronchial  catarrh,  with  cough  and  dyspnoea — 
the  latter,  however,  may  be  due  to  blocking  of  vessels  and  infarc- 
tions. On  auscultation,  a  rather  loud,  systolic  murmer  is  audible,  usually 
with  greatest  intensity  in  the  mitral  area,  or  with  the  second  sound 
in  the  aortic  area.  The  pymmic  form  begins  with  a  chill,  which  is  a 
decided  rigor,  followed  by  a  high  fever  and  sweating.  The  chills  recur 
sometimes  with  the  regularity  of  an  intermittent  fever,  but  usually 
very  irregularly,  as  is  proper  to  pyaemia.  A  condition  of  profound  and 
increasing  adynamia  is  soon  developed.  There  is  often  a  yellowish 
hue  of  the  skin  ;  there  may  be  jaundice,  or  there  may  occur  petechial 
or  haemorrhagic  spots,  or  a  roseola  may  make  its  appearance.  During 
the  maxima  of  the  temperature  curves  the  heat  may  attain  to  105° 
Fahr.  and  the  pulse  to  140.  Dyspnoea  and  accelerated  breathing  may 
indicate  pulmonary  infarctions  and  pneumonia  ;  enlargement  of  the 

*  Rudolf  Maicr,  Virchow's  "  Archiv,"  Band  Ixii,  "  Ein  Fall  von  primarer  Endocar- 
ditis diphtheritica." 


ENDOCARDITIS.  263 

spleen  (infarctions  of  that  organ)  ;  renal  pains,  albuminuria  and  hsema- 
turia  (infarctions  of  the  kidneys) ;  and  apoplectic  attacks  and  hemi- 
plegia (infarctions  of  the  brain).  Abscesses  occur  in  the  joints  in  a 
considerable  proportion  of  cases.  They  are  peculiar,  in  that  they  form 
with  great  rapidity  ;  are,  when  at  rest,  free  from  pain  ;  and  are  not 
manifest  by  swelling  and  changes  in  the  form  and  appearance  of  the 
joint.  In  some  cases  there  occurs  an  acute  atrophy  of  the  liver,  with 
an  intense  icterus.  Confusion  of  mind  is  observed  with  the  onset  of 
the  symptoms,  then  an  active  delirium,  followed  in  a  short  time  by 
stupor,  coma,  and  insensibility.  Not  all  the  cases  conform  to  one  or 
the  other  of  these  types  ;  some  pursue  an  intermediate  course  ;  others 
seem  to  be  only  aggravated  cases  of  rheumatic  fever.  There  may  be 
no  physical  signs  to  warrant  the  opinion  that  endocarditis  exists;  there 
may  be  no  marked  affection  of  the  joints — only  vague  pains  in  them, 
and  in  the  muscles,  yet  there  are  maintained  a  high  grade  of  tempera- 
ture and  a  rapid  pulse,  and  the  stomach  continues  much  deranged. 

Course,  Duration,  and  Termination. — The  course  of  ulcerative  endo- 
carditis is  very  rapid,  but  the  pyaemic  form  is  more  quickly  fatal.  This 
form  rarely  continues  longer  than  ten  days,  and  many  terminate  within 
a  week.  On  the  other  hand,  the  typhoid  form  may  last  three  or  four 
weeks,  or  even  longer.  Death  may  occur  from  paralysis  of  the  heart, 
from  heart-clot,  from  thrombus  of  the  pulmonary  artery,  from  pneu- 
monia, from  cerebral  embolisms,  etc. 

Diagnosis. — A  typical  case  of  the  typhoid  or  pyaemic  form,  occur- 
ring in  the  course  of  acute  rheumatism,  ought  to  be  diagnosticated 
without  difficulty.  Generally  the  symptoms  do  not  indicate  the  nature 
of  the  lesions.  Probably  ulcerative  endocarditis  is  more  frequently 
confounded  with  typhoid  than  any  other  malady.  The  differentiation 
can  not  be  made  from  the  symptoms,  but  from  the  history  of  the  case. 
In  typhoid  there  is  slow  development,  and  the  grave  symptoms  do  not 
come  on  until  the  first  week  is  passed.  The  circumstances  surrounding 
the  individual  and  the  occurrence  of  other  cases  in  the  neighborhood 
must  be  taken  into  account. 

Treatment. — Notwithstanding  the  apparently  hopeless  condition  of 
the  patient  affected  with  ulcerative  endocarditis,  our  efforts  should  be 
directed  to  the  use  of  stimulants  and  support,  and  special  remedies,  as 
if  there  were  a  prospect  of  cure.  As  septic  materials  are  circulating- 
through  the  blood,  the  benzoate  of  ammonium,  or  salicylic  acid,  should 
be  administered  freely.  To  effect  the  solution  of  blood-clots  and  fibrin 
masses,  we  should  keep  the  blood  as  highly  alkalinized  as  possible  by 
ammonium  carbonate.  Quiniae  and  morphia  are  the  appropriate  reme- 
dies during  the  first  few  days;  carbonate  of  ammonia  and  the  benzo- 
ates,  when  the  endocardium  is  disintegrating,  and  alcoholic  stimulants 
and  abundant  food-supply  throughout  the  whole  duration  of  the  case. 


264  DISEASES   OF   THE   HEART. 


DISEASES   OF   THE   VALVES  AND   OP   THE   ORIFIOES.— VALVU- 
LAR   LESIONS. 

Definition. — Under  the  term  "  valvular  disease  "  are  included  those 
alterations  in  the  structure  of  the  valves  themselves,  or  of  the  orifices, 
which  render  the  former  incapable  of  performing  their  office  in  the 
closure  of  the  latter.  The  lesions  may  be  of  two  kinds — obstructive, 
or  regurgitant ;  that  is,  the  orifice  may  be  so  narrowed  as  to  obstruct 
the  passage  of  the  blood,  or  the  valves  may  be  so  damaged  as  to  per- 
mit the  blood  to  regurgitate.  The  narrowing  of  an  orifice  is  termed 
stenosis ;  the  incompetence  of  a  valve  to  close  the  orifice  is  termed 
insufficiency ;  as  aortic  stenosis,  mitral  insufficiency,  etc.  There  are 
four  points  at  which  these  lesions  may  occur  :  on  the  left  side,  at  the 
auriculo-ventricular  orifice  (mitral),  at  the  aortic  orifice  (semi-lunar)  ; 
on  the  right  side,  at  the  auriculo-ventricular  orifice  (tricuspid),  at  the 
pulmonary  orifice  (semi-lunar). 

Causes. — There  seems  to  be  no  difference  in  the  liability  of  the  two 
sexes  respectively  to  the  occurrence  of  valvular  diseases.  Age  exer- 
cises a  very  manifest  influence  in  the  production  of  aortic  disease,  by 
the  development  of  atheromatous  changes,  while  mitral  lesions  occur 
more  frequently  in  youth.  Still,  the  rule  is  not  invariable.  Aortic 
disease  may  be  brought  on  in  early  life  by  overwork  and  strain  of 
the  heart,  as  was  first  pointed  out  by  Da  Costa.  According  to  Bam- 
berger, the  greatest  frequency  of  mitral  disease  is  from  ten  to  thirty, 
and  of  aortic  disease  from  thirty  to  fifty.  The  relative  proportion  of 
cases  fatal  from  heart-diseases,  in  the  deaths  from  all  causes,  is  differ- 
ently stated  by  different  observers,  from  two  per  cent,  to  twenty,  but 
the  lowest  estimate  is  probably  nearest  the  truth.  The  most  impor- 
tant cause  is,  doubtless,  rheumatic  endocarditis,  which  affects  all  the 
valves,  but  greatly  more  frequently  the  mitral.  The  next  in  impor- 
tance as  a  factor  is  chronic  endarteritis,  or  atheromatous  degeneration, 
which  usually  affects  the  aortic  orifice.  Sy^^hilis  is  also  a  cause,  but 
the  precise  value  of  its  influence  in  lighting  up  mischief  in  the  valves 
is  not  known,  and,  as  gummata  are  deposited  in  the  walls  of  the  heart, 
the  lesions  of  the  valves  are  usually  secondary  to  myocarditis.  Lea- 
red  *  reports  a  case  supposed  to  he  syphilitic,  in  which  vegetations 
formed  on  the  aortic  valves,  the  patient  having  had  recently  a  well- 
marked  constitutional  syj^hilis. 

Rational  Signs  and  Symptoms  of  Valvular  Defects. — When  the  nor- 
mal course  of  the  circulation  through  the  heart  is  disturbed  by  changes 
in  the  orifices  and  in  the  valves,  certain  consequences  ensue  to  the 
heart  itself,  and  to  the  organs  in  general.     When  stenosis  exists  at  an 

*  Dr.  A.  H.  Leared,  "  Aortic  Yalve-Disease,  apparently  caused  by  Syphilis,"  "  Path. 
Soc.  Transactions,"  vol.  xix,  p.  94. 


VALVULAR  LESIONS.  265 

orifice,  the  amount  of  blood  passing  through  is  necessarily  lessened, 
with  the  effect  to  cause  ischajmia  and  lowered  tension  in  front,  and 
stasis  and  abnormally  high  tension  behind.  The  same  result  follows 
if  the  contractions  are  feeble  and  the  cavity  dilated,  for  then  the 
amount  delivered  in  front  is  lessened,  and  accumulation  takes  place 
behind.  Lesions  of  the  aortic  orifice,  either  obstructive  or  regurgi- 
tant, lead  to  dilatation  of  the  left  ventricle,  to  diminished  blood-sup- 
ply, and  lowered  tension  in  the  vessels  of  the  aortic  system,  and  to 
increased  pressure  and  distention  in  the  left  auricle  and  pulmonary 
veins.  Mitral  lesions,  either  obstructive  or  regurgitant,  cause  abnor- 
mal fullness  and  distention  of  the  left  auricle  and  pulmonary  system, 
and  ischsemia  and  lowered  tension  in  the  left  ventricle  and  aortic  sys- 
tem. Again,  lesions  of  the  tricuspid  orifice  induce  dilatation  of  the 
right  auricle  and  increased  pressure  in  the  venae  cavse,  and  ischsemia 
and  lowered  pressure  in  the  right  ventricle  and  pulmonary  artery. 
Also,  lesions  of  the  pulmonary  orifice  bring  about  dilatation  of  the 
right  ventricle,  and  elevated  tension  in  the  right  auricle  and  vense 
cavae,  and  ischsemia  and  lowered  tension  in  the  pulmonary  artery.  Al- 
though obstruction  and  regurgitation  of  the  aortic  orifice  affect  first 
the  aortic  system,  yet  ultimately  the  dilatation  of  the  left  ventricle, 
and  the  changes  in  the  auriculo-ventricular  orifice  will  lead  to  incompe- 
tence in  the  mitral  and  general  venous  stasis.  The  same  fact  is  true 
of  mitral  stenosis  and  regurgitation  ;  the  arterial  system  does  not 
receive  its  normal  supply,  and  accumulation  takes  place  in  the  pulmo- 
nary veins,  and  next  in  the  right  cavities.  Obstruction  and  regurgita- 
tion on  the  side  of  the  right  heart  lead  to  ischtemia  in  the  pulmonary 
artery,  then  of  the  pulmonary  veins,  then  of  the  left  cavities,  and 
finally  of  the  aortic  system,  while  stasis  and  high  tension  obtain  in  the 
venous  system.  The  final  result  of  valvular  lesions  on  the  circulatory 
system  may  be  formulated  as  follows  :  All  valvular  lesions  bring  about, 
sooner  or  later,  a  state  of  the  circulatory  organs  in  which  there  are 
ischaemia  and  lowered  tension  in  the  aortic  system  and  stasis  and 
higher  tension  in  the  venous  system.  When  compensation  takes 
place,  this  formulated  expression  ceases  to  be  applicable.  By  the 
term  compensation  is  meant  an  adaptation  of  the  organs  of  circulation 
to  the  new  conditions  imposed  on  them  by  the  valvular  lesions.  Ste- 
nosis of  an  outlet  is  compensated  by  dilatation  of  the  cavity  and  hy- 
pertrophy of  the  walls.  Thus,  in  aortic  stenosis,  some  dilatation  of  the 
cavity  enables  the  heart  to  retain  the  excess  in  the  quantity  of  the 
blood,  and  hypertrophy  of  the  walls  enables  the  left  ventricle  to  de- 
liver the  whole  amount  into  the  aorta.  In  this  way  the  obstruction  is 
compensated,  so  that  the  subjects  of  aortic  stenosis  are  enabled  to  live 
in  comparative  comfort  for  many  years.  But  the  compensation  may 
be  easily  ruptured  or  overcome.  Any  unusual  Avork  put  on  the  heart, 
new  obstacles  inti'oduced  by  disease  in  the  lungs,  or  in  the  heart  itself, 


266  DISEASES   OF   THE   HEART. 

may  disturb  the  comj)ensatory  relation,  and  the  symptoms  of  valvular 
disease  be  resumed  again  with  renewed  force. 

The  slowing  of  the  current,  which  is  a  consequence  of  stenosis,  of 
changes  in  the  heart-muscle,  and  of  stasis  at  some  point  in  the  circuit, 
has  a  disastrous  effect  by  the  formation  of  heai-t-clots.  Coagula  form 
in  various  situations  :  on  the  walls  of  the  heart,  entangled  in  the  tra- 
becular, or  in  the  auricles.  These  coagula  are  found  more  frequently 
on  the  right  side,  and  hence  hasmorrhagic  infarctions  in  the  lungs  are 
results  of  valvular  disease.  A  true  infarction  is  possible  in  those 
organs  only  supplied  with  Cohnheim's  terminal  arteries.  An  embo- 
lus lodged  in  one  of  these  stops  the  blood-current,  and,  the  terminal 
artery  having  no  anastomoses,  there  can  be  no  collateral  circulation  ; 
but  in  the  efferent  vein,  supplied  through  a  communicating  vein  by 
an  unobstructed  artery,  a  recurrent  movement  of  the  blood  takes 
jjlaee,  flows  on  into  the  capillaries,  then  finally  into  the  artery  with  a 
rhythmical  movement.  The  result  is,  the  wedge-shaped  area  sup- 
l^lied  by  the  obstructed  artery  becomes  deeply  injected,  and,  vessels 
yielding  under  the  increased  pressure,  a  haemorrhage  occurs.  Thus 
is  produced  the  pathological  state  called  "  haemorrhagic  infarction." 
If  the  infarction  is  large,  or  if  several  smaller  ones  unite,  symptoms 
of  disturbance  in  the  pulmonary  functions  will  be  induced.  There 
will  be  dyspnoea,  mucous  exjjectoration  with  more  or  less  blood,  chilli- 
ness, and  the  physical  signs  of  consolidation — dullness  on  percussion 
and  bronchial  voice  and  breath  sounds — the  latter,  however,  recog- 
nized if  the  area  of  infarction  be  large  and  situated  at  or  near  the 
periphery.  If  the  pleura  is  involved  there  may  be  pain  and  fever, 
but  usually  the  temperature  remains  rather  below  than  above  the  nor- 
mal. In  some  cases  the  infarction  may  be  entirely  healed,  and  nothing 
remain  but  a  cicatrix ;  in  others,  if  the  embolus  be  infective,  a  gan- 
grenous inflammation  may  take  place  ;  in  others,  again,  death  may 
occur  suddenly  from  blocking  of  a  considerable  vessel. 

The  most  usual  pulmonary  disturbance  induced  by  valvular  disease 
is  stasis  of  the  blood,  which  leads  to  catarrh  of  the  bronchi,  and  is 
accompanied  by  cough,  by  mucous  expectoration,  mucous  and  sub-mu- 
cous rales,  etc.  Very  important  changes  ensue  in  the  intima  of  the  ves- 
sels, and  in  the  caliber  of  the  capillaries  ;  the  former  undergoes  an  atro- 
phic change,  the  latter  enlarge  and  become  varicose,  and,  projecting 
into  the  alveoli,  narrow  the  breathing-space,  and  thus  cause  dyspnoea. 
Under  the  increased  pressure,  vessels  give  way  and  haemorrhage  occurs 
in  the  alveoli  and  intervening  connective  tissue  ;  and  the  blood  un- 
dergoing the  usual  transformation,  produces  the  so-called  "  red-brown 
induration."  When  the  stasis  has  continued  for  a  long  time,  and 
is  extreme,  the  pulmonary  tissue  becomes  oedematous.  Difficulty 
of  breathing  is  a  necessary  result  of  these  conditions.  Besides  this 
habitual  difficulty  of  breathing,  there  are  paroxysmal  attacks  of  con- 


VALVULAR   LESIOXS.  267 

siderable  severity,  in  which,  without  any  increase  in  the  number  of 
respiratory  movements,  there  is  a  sense  of  need  of  air,  accompanied 
often  by  pain  in  the  chest,  in  the  shoulder,  and  extending  down  the 
arm.  These  attacks  are  more  usual  in  cases  of  disease  at  the  aortic 
ostium,  due  to  atheromatous  degeneration.  In  consequence  of  the 
slow  circulation  through  the  tissues,  the  blood  loses  more  oxygen  and 
takes  up  more  carbonic  acid  ;  in  consequence  of  the  interference  with 
aei'ation  caused  by  the  pulmonary  changes,  the  blood  contains  always 
more  carbonic  acid  and  less  oxygen  than  is  normal — hence  cyanosis  is  a 
symptom  in  these  cases.  It  exists,  in  varying  degree,  from  a  decided 
blueness  of  the  whole  surface  to  a  faint  blueness  of  the  lips  only.  The 
condition  of  over-fullness  of  the  venous  system  is  further  seen  in  the 
distended  state  of  the  superficial  veins.  The  increased  tension  of  the 
veins  is  an  efficient  factor  in  the  production  of  oedema,  the  absorption 
of  fluid  is  hindered  from  the  same  cause,  and  the  state  of  the  blood- 
serum  favors  outward  rather  than  inward  osmosis.  The  accumulation 
of  fluid  in  the  areolar  tissue  first  occurs  in  the  inferior  extremities,  and 
then  gradually  extends  upward.  Of  the  internal  cavities,  the  perito- 
neum becomes  earliest  and  most  abundantly  the  seat  of  effusion,  be- 
cause of  the  changes  which  take  place  in  the  liver  in  these  cases  of 
cardiac  disease  (see  Coxgestion  of  the  Liver).  Next  to  the  perito- 
neum, the  left  pleural  cavity  contains  the  most  transudation  ;  next  the 
sac  of  the  pericardium.  The  severe  pressure  on  the  skin  of  the  legs, 
which  is  also  filled  with  serum,  leads  to  inflammation  of  the  skin  ;  it 
becomes  tense,  brawny,  and  congested,  and  finally  ulcerates,  forming 
a  more  or  less  extensive  purplish  excavation,  exuding  serum  constantly. 
The  ulcer  or  ulcers  thus  produced  are  liable  to  attacks  of  erysipelatous 
inflammation,  to  sloughing,  and  to  deep-seated,  burrowing  suppuration. 
The  condition  of  the  blood  which  contributes  to  dropsical  accumu- 
lation is  produced  by  several  factors.  The  loss  of  albumen  and  salts 
has  the  effect  to  prevent  osmosis  into  the  vessels  of  fluid  in  the  tissues, 
which  therefore  accumulates,  and  the  hepatic  derangement  and  chronic 
gastric  catarrh,  which  interfere  very  seriously  with  digestion  and  the 
absorption  of  its  products.  The  aiDj)etite  is  either  wanting  or  capri- 
cious ;  food  distresses  the  stomach  ;  the  intestines  are  filled  with  gas, 
the  result  of  the  decomposition  of  certain  kinds  of  food  ;  and  diarrhoea, 
which  nothing  controls  permanently,  comes  on  toward  the  close.  The 
continued  hypersemia  of  the  liver  causes  that  appearance  known  as 
"nutmeg-liver,"  the  connective  tissue  undergoes  hyperplasia,  and  the 
organ,  after  a  period  of  enlargement,  contracts  more  or  less.  This 
state  is  often  confounded  with  "  cirrhosis,"  but  the  morbid  process  is 
different.  The  kidneys  are  affected  by  the  variations  in  the  tension 
of  the  vascular  system.  As  a  smaller  quantity  of  blood  than  normal 
passes  through  the  tufts  of  the  glomeruli,  the  amount  of  urinary  water 
decreases,  and  hence  the  urine  is  scanty  in  quantity,  has  a  high  spe- 


268  DISEASES   OF   THE   HEART. 

cific  gravity,  deposits  abundantly  of  urates,  and  finally  becomes  albu- 
minous as  the  tension  increases  in  the  venous  system.  The  urine  also 
contains  much  pigment,  but  there  is  rarely  any  blood  present,  and  there 
are  hyaline  casts.  The  first  effect  of  the  persistent  venous  congestion 
is  enlargement,  due  to  over-production  of  connective  tissue,  but  in  the 
progress  of  the  case  atrophy  occurs  and  the  organs  become  reduced  in 
size,  very  tough,  and  dark-purplish  in  color.  These  atrophic  changes 
are  due  to  the  pressure  of  the  contracting  connective  tissue  and  con- 
sequent wasting  of  the  proper  gland  elements.  During  these  altera- 
tions the  tubular  epithelium  becomes  granular  and  ultimately  fatty, 
whUe  the  basement  membrane  also  undergoes  thickening.  Infarctions 
sometimes  occur  in  the  kidney  during  the  course  of  chronic  cardiac 
disease  ;  they  are  due  to  obstruction  in  the  branches  of  the  renal 
artery  by  emboli ;  they  assume  the  characteristic  wedge-shape,  with 
the  apex  toward  the  hilus,  and  they  undergo  the  same  changes  as  in- 
farctions elsewhere. 

Very  characteristic  cerebral  symptoms  are  also  produced  by  car- 
diac valvular  lesions,  but  they  vary  in  character  according  to  the  valves 
affected.  The  disturbed  state  of  the  intra-cranial  circulation  thus  occa- 
sioned doubtless  leads  to  nutritive  alterations  in  the  walls  of  the  cere- 
bral vessels.  Furthermore,  atheromatous  change  at  the  aortic  orifice 
will  be  followed  by  similar  changes  in  the  intra-cranial  arteries.  Mil- 
iary aneurisms  form  when  the  walls  of  the  small  arteries  undergo  these 
changes.  Rupture  and  consequent  extravasation  will  then  take  place 
readily,  because  of  the  variations  in  tension  of  the  blood-vessels.  Em- 
bolism of  the  brain  is  exceedingly  common  in  recent  cases  of  endocar- 
ditis. Owing  to  the  position  of  the  left  carotid  and  the  left  middle 
cerebral,  it  is  pretty  certain  that  an  embolus  dislodged  from  the  valves 
of  the  left  side  of  the  heart  will  be  deposited  somewhere  within  the 
area  of  distribution  of  the  left  middle  cerebral  artery.  Hence  the  fre- 
quent association  of  acute  rheumatism,  valvular  disease  of  the  heart, 
and  right  hemij^legia,  with  aj)hasia.  Without  causing  organic  lesions 
of  any  kind,  very  unpleasant  and  severe  symptoms  of  intra-cranial 
disturbance  are  produced  by  valvular  lesions,  especially  those  of  the 
aortic  orifice.  Xarrowing  and  obstruction,  or  regurgitation  at  the  aorta, 
must  necessarily  produce  anaemia  of  the  brain,  with  the  usual  symp- 
toms of  that  condition,  as  sudden  faintness,  dizziness,  tinnitus  auriuni, 
persistent  headache,  etc.  Chorea  has  long  been  associated  with  endo- 
carditis. According  to  the  well-known  theory  of  Jackson,  chorea  is 
due  to  multiplex  capillary  embolisms  of  the  corpus  striatum,  but  this 
view  is  not  generally  accepted.  In  a  large  proportion — probably  in 
one  fourth — chorea  is  associated  with  rheumatic  endocarditis,  but  the 
exact  nature  of  the  relation  is  not  now  understood. 


VALVULAR  LESIONS.  269 

AFFECTIONS  OF  THE  AORTIC  VALVES  AND  ORIFICE.— The 

alterations  which  occur  in  the  aortic  valves  are  very  numerous,  as  re- 
spects the  character  of  the  resulting  deformity.  The  segments  may 
be  adherent  by  their  lateral  planes,  leaving  a  central  opening  through 
which  only  the  little  finger  may  protrude.  A  segment  may  be  torn 
from  its  base  in  part  or  almost  wholly.*  This  accident  may  result 
from  a  suppurating  myocarditis,  which  so  weakens  the  attachment 
of  the  valve  that  it  gives  way  while  in  the  perfomiance  of  the  ordi- 
nary functions.  Such  a  degree  of  shortening  and  rigidity  may  ensue 
that  the  segments  can  not  successfully  approximate,  or  this  change 
may  take  place  in  one  or  two  segments.  Besides  rigidity  and  thick- 
ening, the  valves  may  be  deformed  by  ragged,  dentated,  and  rough- 
ened margins.  The  margins  of  the  segments  may  become  thinned 
and  slits  form,  presenting  the  appearance  known  as  "fenestrated," 
or  the  so-called  valvular  aneurisms  may  occur,  and,  giving  way,  open- 
ings are  made  which  render  the  valve  incompetent.  Atheromatous 
changes  beginning  in  the  aorta  extend  downward  to  the  orifices, 
producing  rigidity,  narrowing,  and  deformity.  Rough  excrescences 
form  and  project  into  the  ostium,  and  so  small  may  it  finally  become 
that  the  smallest  finger  will  barely  pass  through.  The  valves  also 
become  much  altered  by  calcareous  deposits  ;  they  become  rigid, 
roughened,  and  incompetent.  As  a  result  of  the  changes  in  the  valves 
and  orifices — stenosis  and  insufficiency — the  left  ventricle  is  kept  too 
full  and  the  cavity  dilates.  The  septum  between  the  ventricles  is 
pushed  over  by  the  distention,  encroaching  on  the  right  ventricular 
cavity  ;  the  auriculo-ventricular  orifice  is  stretched,  and  the  segments 
of  the  mitral  are  drawn  on  and  lengthened.  The  increased  labor  im- 
posed on  the  muscle  of  the  left  ventricle,  to  propel  the  blood  into  the 
aorta,  induces  an  hypertrophy,  and  consequently  the  walls  become 
thicker  as  the  cavity  enlarges,  although  the  growth  of  the  walls  is  not 
X)ari  passu.  The  papillary  muscles  are  stretched  and  flattened  by  the 
strain  of  the  diastole,  and  are  not  hypertrophied. 

Symptoms  of  Stenosis,  Rational  and  Physical. — The  character  of  the 
pulse  has  high  significance.  The  ostium  being  small  and  the  ventricle 
hypertrophied,  the  pulse  is  small,  slow,  and  hard.    The  sphygmo graphic 


Fig.  18.— Stenosis  of  Aortic  Orifice. 

tracing  exhibits  these  characters  clearly.  The  ascensional  line  is  rather 
oblique,  the  summit  rounded,  the  abscissa  low,  the  descending  line  ob- 
lique, and  the  interval  long  ;  almost  the  opposite  of  the  tracing  in  in- 
sufficiency.   The  supply  of  blood  to  the  brain  is  insufficient,  and  hence 

*  Dr.  Burney-Yeo,  "Lancet,"  December  5, 18Y4,  "Clinical  Lectures  on  Rupture  of  the 
Aortic  Valves." 


270 


DISEASES   OF   THE   HEART. 


there  are  attacks  of  headache,  vertigo,  syncope,  and  the  patient  may- 
fall  suddenly  relaxed,  with  or  without  losing  consciousness,  or  there 
may  occur  distinctly  epileptiform  seizures.  The  diminution  in  the 
quantity  of  blood  passing  to  the  brain  may  be  the  cause  of  serious  nu- 
tritive derangements  in  the  organ.  The  left  ventricle  undergoes  dila- 
tation and  hypertrophy,  and,  the  mitral  becoming  incompetent,  stasis 
takes  place  on  the  venous  side.  The  lungs  are  kept  abnormally  full, 
haemoptysis  and  infarctions  may  occur,  dyspnoea  is  paroxysmal,  and 
thei'e  may  be  attacks  similar  to  angina  pectoris.  In  the  progress  of 
the  case  the  heart  becomes  less  capable  of  overcoming  the  resistance, 
and  then,  instead  of  a  hard  pulse,  it  becomes  soft  and  weak.  On  pal- 
pation, the  apical  impulse  has  the  position  usual  in  hypertrophy,  but 
it  is  much  weaker  than  when  there  is  insufficiency  of  the  valves,  and 
may,  indeed,  be  scarcely  perceptible.  On  percussion,  the  area  of  dull- 
ness is  somewhat  increased  in  the  long  axis,  but  little  transversely,  if 
at  all.  Auscultation  furnishes  a  rasping,  whistling,  singing,  or  musical 
murmur,  according  to  the  character  of  the  obstruction,  and  it  is  sys- 
tolic in  time,  audible  with  greatest  intensity  in  the  aortic  area — at  the 
junction  of  the  right  third  costal  cartilage  with  the  sternum.  It  may 
be  very  loud  and  audible  a  short  distance  from  the  patient.  If  there 
be  regurgitation  also,  a  diastolic  murmur  will  be  produced.  The  dias- 
tolic normal  sound  will  be  weak  because  of  the  diminished  elasticity 
and  imperfect  closure  of  the  valve-segments.  So  long  as  compensation 
continues  there  may  be  no  pronounced  symptoms,  and  the  heart  may 
be  equal  to  the  ordinary  duties  required  of  it.  When  the  comjDensation 
is  ruptured  by  overwork  of  the  heart,  or  by  the  occurrence  of  disease, 
then  stasis  will  ensue  in  the  venous  system  and  dropsy  will  occur.  In 
other  cases  the  amount  of  obstacle  is  too  great,  and  the  compensation 
is  imperfect ;  then  the  disturbances  due  to  the  nature  of  the  lesion 
will  slowly  develop. 

Symptoms  of  Insufficiency,  Rational  and  Physical. — The  pulse  has  a 


Fig.  19.— Pulse  of  Aortic  Regurgitation. 


very  different  character  from  that  in  stenosis.  The  amplitude  of  the 
wave  is  great,  the  rise  in  the  beat  sudden,  its  declension  rapid.  It 
is  known  as  the  "water-hammer"  pulse,  or  as  the  "  Corrigan  pulse," 
from  Sir  Dominic  Corrigan,  who  described  it.  The  sphygmographic 
tracing  clearly  indicates  these  qualities  :  the  ascent  is  vertical,  the  ab- 


VALVULAR  LESIONS.  271 

sciss  lofty,  the  descent  abrupt,  and,  if  the  case  is  purely  one  of  re- 
gurgitation without  other  defect,  the  descent  is  not  marked  by 
the  secondary  wave  produced  by  the  closure  of  the  valve  and  the 
recoil  of  the  current.  If  there  is  no  stenosis,  so  strongly  is  the  blood 
propelled  into  the  arteries  that  small  vessels  not  before  visible  pul- 
sate distinctly.  This  condition  of  things  produces  the  pulsation  of 
the  retinal  vessels  which  may  be  recognized  by  the  use  of  the  ophthal- 
moscope. 

So  long  as  this  valvular  defect  is  compensated  by  dilatation  of  the 
left  ventricle,  and  hypertrophy  of  the  walls — excentric  hypertrophy — 
the  objective  and  subjective  symptoms  are  not  very  pronounced.  There 
are  usually  a  good  deal  of  headache — the  pain  pulsating  synchronously 
with  the  heart-beat — more  or  less  dizziness,  and  pulsation,  and  tin- 
nitus  aurium.  When  associated  with  atheromatous  changes  of  the 
intra-cranial  vessels,  there  is  great  danger  of  cerebral  haemorrhage. 
When  similar  changes  have  occurred  in  the  aorta  and  coronary 
artery,  attacks  of  angina  pectoris  may  take  place.  So  long  as  the 
compensation  continues  unruptured,  there  will  be  no  difficulty  in 
breathing,  no  stasis  in  the  venous  system,  no  dropsy  ;  but,  if  from  any 
cause  the  compensation  becomes  unequal,  then  there  will  ensue  the  or- 
dinary series  of  phenomena — dyspnoea,  cough,  enlargement  of  the  liver, 
congestion  of  the  kidneys,  albuminuria,  ascites  and  dropsy.  As  these  j  ^ 
cases  may  continue  for  years  with  the  lesions  compensated,  the  prog- 1  , 
nosis  is  more  favorable  than  in  any  other  form  of  organic  cardiac  dis-  \ 
ease.  As  soon  as  the  mitral  becomes  incompetent,  dyspnoea  begins,  the 
initial  symptom,  usually,  of  the  widespread  disturbance  which  comes 
on  in  the  fully  developed  cases. 

In  aortic  insufficiency,  there  are  present  the  signs  of  hypertrophy  : 
the  area  of  dullness,  especially  the  absolute  dullness,  is  increased  both 
in  the  vertical  and  transverse  diameter,  as  has  been  already  point- 
ed out  in  the  discussion  of  hypertrophy  of  the  heart.  The  murmur 
proper  to  aortic  insufficiency  is  a  churning,  rushing,  diastolic  murmur, 
heard  at  the  time  and  taking  the  place  of  the  normal  murmur,  and 
audible  at  the  aortic  area — at  the  junction  of  the  Jgft  third-rib  cartilage  ' 
with  the  sternum.  Also,  there  is  usually,  independently  of  stenosis,  a 
systolic  murmur  heard  along  the  aorta  and  carotids,  produced  prob- 
ably by  the  movements  of  the  column  of  blood  in  the  dilated  aorta, 
and  by  the  vibration  imparted  to  the  walls  of  these  vessels  by  the 
force  of  the  impulsion.  This  is  a  rather  soft  and  blowing  murmur, 
not  unlike  the  murmur  of  anaemia  heard  in  the  same  situation.  It  has 
been  shown,  further,  that  a  reduplicated  sound — systolic  and  diastolic 
— is  audible  in  the  femoral  artery  without  pressure  when  there  is  a 
marked  degree  of  valvular  insufficiency,  and  it  may  be  developed  when 
there  is  but  little  insufficiency,  by  pressure  above  and  below  the  steth- 
oscope.    This  reduplicated  sound  should  not  be  confounded  with  the 


272  DISEASES  OF  THE   HEART. 

hruit  which  can  be  produced  by  pressure  of  the  stethoscope  on  any 
artery,  and  which  is  a  single  sound. 

Affections  of  the  Mitral  Valve  and  Orifice. — More  frequently  than 
at  the  aortic  orifice,  the  changes  in  the  valves  are  results  of  endocardi- 
tis— aplastic  or  verrucose  endocarditis.  Atheroma  and  calcareous  depo- 
sition are  not  such  important  factors  as  in  lesions  of  the  aortic  orifice. 
Various  changes  occur  in  the  segments  of  the  mitral.  One  may  be- 
come adherent  to  the  ventricular  wall ;  the  two  segments  may  be 
united,  the  chordae  tendinse  of  one  segment  breaking  off ;  there  may 
be  thickening  and  contraction  of  each  ;  the  borders  of  the  segments 
may  be  ragged,  thickened  by  new  tissue,  and  at  the  same  time  con- 
tracted so  as  to  be  quite  too  small  to  close  the  orifice  ;  there  may  be 
perforations  of  the  valves  by  giving  way  of  the  so-called  aneurisms  or 
by  ulcerations,  and  lastly  the  valves  may  unite,  leaving  a  small  central 
orifice.  The  margins  of  the  ostium  may  also  be  thickened  and  nar- 
rowed by  inflammatory  changes  ;  there  may  be  calcareous  deposits, 
roughening  and  obstructing  it,  or  the  ostium  may  be  enlarged  by  dila- 
tation of  the  cavity  so  that  the  valves,  although  normal,  are  unable  to 
close  it  perfectly.  Insufficiency  of  the  mitral  may  occur  alone,  but 
usually  stenosis  and  insufficiency  occur  together,  and  stenosis  never, 
probably,  without  insufficiency.  Whether  insufficiency  or  stenosis,  the 
result  is,  that  the  left  ventricle  is  inadequately  supplied  with  blood  to 
distribute  through  the  systemic  vessels.  The  left  auricle  is  over-dis- 
tended, and  the  tension  in  the  pulmonary  veins  is  high.  The  walls  of 
the  auricle  are  hypertrophied,  and  the  endocardium  is  cloudy  in  con- 
sequence of  nutritive  changes.  The  intima  of  the  pulmonary  veins  is 
altered  by  proliferation  of  its  connective-tissue  corpuscles,  and  by  fatty 
degeneration.  The  pulmonary  veins,  the  pulmonary  artery,  the  right 
cavities,  and  the  venae  cavas,  are  kept  over-distended  and  in  abnor- 
mally high  tension,  because  the  blood  is  pumped  back  through,  or  can 
not  pass  through,  the  mitral  orifice,  and  there  is,  therefore,  ischemia 
and  low  tension  in  the  aortic  system. 

Sjrmptoms  of  Stenosis,  Rational  and  Physical. — Having  unusual 
work  to  do  to  overcome  the  obstruction  in  front,  the  left  auricle  be- 
comes hypertrophied.  The  left  ventricle,  having  less  volume  of  blood 
to  discharge,  diminishes  in  size  somewhat,  and  the  aorta  also  is  re- 
duced in  caliber,  but  this  is  not  invariably  the  case,  for  there  is  often 
either  a  normal  size  of  the  ventricle  or  it  actually  becomes  enlarged. 
For  example,  in  a  case  of  mitral  stenosis  narrated  by  Balfour,  where  the 
segments  were  "  glued  together  by  their  margins,"  and  "  the  opening  ■ 
was  so  extremely  contracted  as  only  to  permit  the  point  of  the  little 
finger,"  it  is  stated  that  the  "  left  ventricle  is  slightly  hypertrophied, 
not  dilated."  *     The  chief  reason  why,  under  a  diminished  volume  of 

*  "  Diseases  of  the  Heart,"  p.  136. 


VALVULAR  LESIONS.  273 

blood,  the  left  ventricle  may  undergo  hypertrophy,  is  that  the  contrac- 
tile energy  expended  is  necessarily  increased,  because  of  the  obstacles 
in  the  circuit.     The  pulse  is  small,  its  tension  low,  and  its  rhythm 


Fig.  20.— Mitral. 


irregular,*  but  the  irregularity  is  not  constantly  present,  and  is  a  sign  ~^ 
rather  of  rupture  oJ..the  compen_satk)n.  There  are  much  cough,  diffi- 
culty of  breathing,  bronchorrhoea,  often  bloody  sputa,  sometimes 
haemorrhage,  red-broAvn  induration  and  hemorrhagic  infarctions  ;  dila- 
tation of  the  right  cavities  ;  general  venous  stasis,  cyanosis  ;  enlarge- 
ment of  the  liver,  ascites  ;  albuminous  urine,  and  general  dropsy. 
By  enlargement  and  hypertrophy  of  the  left  auricle,  by  dilatation 
and  hypertrophy  of  the  right  ventricle,  and  by  the  distention  of  the 
veins,  the  stenosis  is  for  a  brief  period  compensated.  But  the  condi- 
tions present  bring  about  a  slow  rupture  of  the  compensation,  without 
the  introduction  of  new  disturbances.  The  changes  in  the  muscular 
tissue  of  the  right  heart,  the  degeneration  of  the  walls  of  the  dilated 
vessels,  and  the  alterations  produced  by  the  congestion  of  the  liver, 
intestinal  canal  and  kidneys,  suffice  to  bring  on  the  group  of  disorders 
above  mentioned,  which  belong  to  the  mitral  lesions.  The  rupture  of 
the  compensation  is  much  facilitated  by  overwork  of  the  heart,  by 
pulmonary  diseases,  or  by  intercurrent  febrile  maladies.  On  inspec- 
tion, rather  wide  diffusion  of  the  apical  impulse  is  perceived,  if  there 
be  an  apical  impulse  strong  enough  for  recognition.  It  is  rather  a 
widespread  undulation  than  an  impulse  at  a  special  point.  It  extends 
from  within  the  mammillary  line  to  the  right  border  of  the  sternum 
and  downward  to  the  epigastrium.  It  may  be  absent.  On  palpation 
the  apical  impulse  is  found  to  be  weak  and  unresisting,  and  a  purring 
tremor  is  felt  which  may  be  diastolic  or  presystolic.  If  there  be  re- 
gurgitation, a  purring  tremor  may  also  be  felt  synchronous  with  the 
systole.     Both  absolute  and  relative  dullness  are  increased. 

The  transverse  dullness  is  more  increased  than  the  vertical,  and 
extends  to  the  right  border  of  the  sternum,  even  beyond,  and  over  the 
xiphoid  appendix.  A  murmur  is  audible  in  the  mitral  area,  of  a  rather 
harsh,  grating,  or  blowing  character,  and  occurring  with  the  diastole 
and  extending  on  up  to  the  systole.  The  murmur  may  be  presystolic 
— that  is,  occurring  just  before  and  extending  in  to  the  systole,  but 
there  are  differences  of  opinion  in  respect  to  the  time  of  this  murmur. 
The  murmur  is  usually  heard  with  greater  distinctness  when  the  patient 

*  Balfour,  "  Diseases  of  the  Heart,"  "Extreme  Irregularity,"  p.  126. 

18 


27i  DISEASES   OF  THE   HEART. 

sits  upright  leaning  f orwai-d,  or  to  the  left.  No  murmur  may  be  audi- 
ble in  some  cases  under  any  circumstances.  Then  the  rational  signs 
of  mitral  lesions  possess  a  high  degree  of  significance,  and  deserve 
attentive  study,  and  a  failure  to  appreciate  their  value  and  overween- 
ing attention  to  the  physical  signs  are  fruitful  sources  of  error,  under 
these  circumstances.  While,  when  present,  the  murmurs  are  heard 
in  the  mitral  area  with  the  greatest  distinctness,  they  are  propagated 
toward  the  apex,  and  lost  toward  the  base.  In  a  few  cases  of  steno- 
sis, another  sign  is  to  be  heard  over  the  apex,  and  at  the  pulmonary 
area,  namely,  reduplication  of  the  second  sound.  Various  explana- 
tions of  this  phenomenon  have  been  offered,  but  the  most  probable 
is  that  the  aortic  and  pulmonary  valves  do  not  close  in  the  same 
instant  of  time,  owing  to  the  difference  in  tension  of  the  aorta  and 
pulmonary  artery,  the  tension  of  the  latter  being  relatively  greater 
and  therefore  closing  before  the  former.  There  is  a  sharp  accentua- 
tion of  the  second  sound  in  the  pulmonary  area,  when  the  reduplication 
does  not  occur,  owing  to  the  high  tension  under  which  the  valves  are 
filled  and  closed.  This  characteristic  of  the  second  sound  will  disap- 
pear when  the  tension  of  the  vessels  declines  from  any  cause  or  when 
the  tricuspid  becomes  incompetent. 

Symptoms  of  Regurgitation  or  Insuffleiency,  Rational  and  Physical. — 
So  long  as  the  compensation  continues,  the  patient  may  be  compara- 
tively free  from  discomfort,  but  the  existence  of  these  circulatory  de- 
rangements leads  to  pathological  changes  which  effect  a  rupture  of 
the  compensation — e.  g.,  the  pulmonary  disorders,  which  are  thus 
brought  about,  the  myocarditis  which  attacks  the  walls  of  the  right 
ventricle,  or  an  intercurrent  disease  of  some  kind.  Prascordial  uneasi- 
ness, palpitation,  cough,  and  dyspnoea  are  the  first  symptoms  experi- 
enced when  the  compensation  is  ruptured.  The  pulse  becomes  soft, 
small,  rapid,  and  irregular,  and  while  the  sphygmographic  trace  ex- 
hibits these  features  there  is  nothing  distinctive  in  its  form.      The 


Fig.  21. — Mitral  Valvular  Disease. 


legs,  presently,  become  oedematous,  the  cavity  of  the  abdomen  fills, 
the  liver  is  disordered,  the  urine  is  loaded  with  albumen,  and  the  pa- 
tient ultimately  dies  drowned  in  his  own  fluids.  The  physical  signs 
are  characteristic.  As  in  insufficiency  of  the  mitral,  there  is  more  or 
less,  usually  considerable  hypertrophy  of  the  left  ventricle,  enlarge- 
ment of  the  cavity  and  thickening  of  the  walls  of  the  left  auricle,  hy- 
pertrophy and  dilatation  of  the  right  ventricle  ;  the  total  result  is  that 
the  heart  is  much  enlarged,  and  lies  lower  and  deeper  than  is  the  nor- 
mal condition.     The  area  of  dullness,  absolute  and  relative,  vertical 


VALVULAR   LESIONS.  275 

and  transverse,  is  enlarged,  and  the  cardiac  impulse  diffused.  On 
auscultation  a  systolic  blowing  murmur  is  audible  in  the  mitral  area, 
is  propagated  toward  the  apex,  and  may  be  most  intense  at  the  very 
extremity  of  the  apex.  This  systolic  bruit  may  also,  when  loud  and 
strong,  be  heard  over  the  whole  cardiac  area,  and  posteriorly  under  the 
angle  of  the  scapula  ;  it  may  take  the  place  of  the  first  sound,  or  be 
heard  with  it.  Usually  the  murmur  can  be  separated  from  the  proper 
systolic  sound,  by  very  carefully  raising  the  head  from  the  stethoscope 
so  that  the  ear  but  touches  it>.  Sometimes  the  bruit  is  heard  with  the 
greatest  intensity  in  the  second  intercostal  space,  external  to  the  left 
border  of  the  sternum,  in  the  position  of  the  appendix  of  the  left  auricle, 
and  because  of  the  regurgitating  blood  like  "the  fluid  in  veins  produc- 
ing sonorous  vibrations  louder  at  the  point  of  impingement  than  at  that 
of  origin  "  (Balfour),  This,  the  explanation  of  Naunyn,  is  now  gener- 
ally admitted.  If  there  be  obstruction  as  well  as  regurgitation  at  the 
mitral  orifice,  there  will  be,  as  already  set  forth,  a  presystolic  murmur, 
extending  up  to  the  systole,  or  under  some  circumstances  a  diastolic 
murmui-.  In  regurgitation,  as  in  stenosis,  there  is  marked  accentuation 
of  the  pulmonary  second  sound,  until,  at  least,  dilatation  of  the  cavity 
and  incompetence  of  the  tricuspid  introduce  new  conditions. 

The  diagnosis  of  mitral  disease  must  rest  on  a  careful  survey  of  the 
rational  and  physical  signs.  Too  strict  attention  to  the  physical  and 
neglect  of  the  rational  signs  are  frequent  sources  of  error.  Exact 
localization  of  the  murmurs  to  the  areas  to  which  they  belong  is  most 
important.  The  history  of  the  case  necessarily  enters  into  the  ques- 
tion of  its  nature.  When  the  indications  afforded  by  the  history  of 
the  case  and  the  rational  and  j)hysical  signs  coincide,  any  serious  error 
is  hardly  possible. 

AFFECTIONS    OF    THE    TRICUSPID   VALVE   AND    ORIFICE 

Only  once  or  twice,  in  one  hundred  cases  of  endocarditis,  will  the 
right  auriculo-ventricular  orifice  be  the  seat  of  mischief,  and  then 
in  association  with  similar  changes  on  the  other  side  of  the  heart, 
at  the  mitral  orifice.  Stenosis  of  the  left  auriculo-ventricular  orifice 
and  obstructive  diseases  of  the  lungs  cause  distention  of  the  right 
ventricle  and  produce  that  kind  of  insufficiency  which  is  known  as 
relative  insufficiency.  Regurgitation  takes  place  through  this  orifice, 
because,  being  enlarged,  the  valves  become  unable  to  close  it  during 
the  systole.  Over-distention  of  the  auricle  and  hypertrophy  result 
from  the  regurgitation,  and  the  tension  rises  in  the  venae  cavse  and 
venous  system,  while  there  are  ischaemia  and  diminished  tension  in 
the  aortic  system.  The  right  ventricle  also  undergoes  hypertrophy, 
because  it  is  filled  under  the  increased  pressure  of  the  high  tension 
in  the  veins  and  the  hypertrophy  of  the  auricle.  Regurgitation  is 
often  due  to  changes  in  structure  that  are  congenital,  and  stenosis 


276  DISEASES   OF  THE   HEART. 

almost  always.  Very  rarely  is  stenosis  produced  by  acute  endo- 
carditis, and,  when  it  does  occur  from  this  cause,  the  anatomical 
changes  are  precisely  those  which  have  been  described  as  taking  place 
on  the  other  side.  The  results  of  stenosis  are  the  same  as  those  of 
regurgitation,  and  need  not,  therefore,  be  repeated  ;  but  stenosis  never 
exists  alone,  and  is  always  associated  with  changes  on  the  left  side. 
The  pulse  is  small,  weak,  but  not  otherwise  altered.  A  very  charac- 
teristic symptom  is  the  occurrence  of  a  pulsation  in  the  jugular, 
synchronous- with  the  cardiac  movement.  It  ought  not  to  be  forgotten 
that  waves  are  caused  in  the  jugular  by  the  respiratory  movement — 
by  the  expiratory  pressure.  The  true  venous  pulse  does  not  extend 
beyond  the  bulb  of  the  jugular,  if  the  valves  of  the  vein  are  intact, 
but  by  distention  they  become  so,  when  the  venous  pulse  is  perceived 
along  the  whole  extent  of  the  vessel,  extending  even  to  the  external 
jugular.  It  is  synchronous  with  the  contractions  of  the  heart.  The 
pulsation  may  be  double,  produced  by  the  contraction  of  the  auricle, 
and  by  the  beating  of  the  aorta,  the  vena  cava  superior  lying  in  close 
proximity  to  that  vessel.  There  is  a  feeble  venous  pulsation  when  there 
is  regurgitation  at  the  mitral  orifice,  a  stronger  one  with  coincident  in- 
sufficiency of  the  tricuspid,  and  with  the  latter  alone.  That  this  pulsa- 
tion is  produ-ced  by  the  lesions  above  mentioned,  and  is  not  an  oscilla- 
tion in  the  blood-current  caused  in  the  various  ways  already  described, 
is  determined  by  merely  compressing  the  vessel  with  the  finger,  when 
the  following  facts  will  be  elicited  :  If  the  pulsation  be  due  to  the 
heart-movements  (regurgitation),  when  the  vein  is  compressed  at  its 
middle,  it  will  continue  below  the  j^oint  of  compression  and  cease 
above  ;  if  due  to  the  beating  of  the  carotid,  it  will  continue  above  the 
point  of  compression,  and  cease  below.  If  due  to  the  respiratory 
movements,  the  pulsation  will  be  synchronous  with  those  movements  ; 
if  to  the  heart-movements,  sychronous  with  them  ;  if  respiratory,  they 
will  cease  with  the  suspension  of  breathing;  and,  if  cardiac,  will  continue. 
There  is  an  equally  characteristic  venous  pulse  of  the  liver,  which  is 
felt  immediately  on  the  occurrence  of  the  changes  on  the  right  side  of 
the  heart,  because  the  hejoatic  veins  are  not  provided  with  valves. 
The  pulsation,  synchronous  with  the  cardiac  movements,  may  be  felt 
over  the  whole  organ,  or  be  confined  to  the  right  lobe.  The  venous 
pulsation  in  the  neck  may  appear  and  disappear  under  the  variations 
in  the  fullness  of  the  right  cavities  and  the  force  of  the  ventricular 
contractions.  The  hepatic  pulsation  is  affected  by  effusions  in  the 
abdomen,  as  well  as  by  the  state  of  distention  of  the  vena  cava  and 
the  hypertrophy  of  the  right  ventricle.  So  long  as  the  valves  of  the 
jugular  remain  intact,  the  increased  tension  under  which  their  closure 
is  effected  causes  a  murmur,  humming  and  clacking  combined,  which 
is  audible  in  the  bulb.  The  hypertrophy  existing  chiefly  to  the  right, 
the  area  of  impulse  must  be  seen  to  the  right,  and  is  rather  diffused. 


VALVULAR  LESIONS. 


277 


Dullness  on  percussion,  due  to  the  enlarged  right  auricle,  can  be  de- 
veloped to  the  right  of  the  sternum  from  the  second  to  the  fourth 
rib,  and  the  dullness  due  to  the  right  ventricle,  to  the  base  of  the 
sternum,  to  the  xiphoid  appendix,  and  to  the  central  and  right  portion 
of  the  epigastric  region.  A  pulsation  produced  by  the  right  auricle 
can  be  seen  and  felt  sometimes  in  the  right,  second  intercostal  space. 
On  auscultation  in  the  tricuspid  area — the  lower  segment  of  the  ster- 
num— we  hear  a  blowing  murmur,  systolic  in  time,  and  most  intense 
at  the  junction  of  the  intercostal  space  between  the  fourth  and  fifth 
rib  and  the  sternum  ;  sometimes,  most  intense  over  the  xiphoid  ap- 
pendix. This  is  the  characteristic  murmur,  but  there  are  associated 
with  it  the  valvular  mitral  murmurs  which  almost  always  are  present, 
and  are  audible  with  the  greatest  intensity  at  the  mitral  area  and 
toward  the  apex.  These  are  both  systolic,  presystolic,  and  diastolic, 
as  has  been  pointed  out.  In  the  affections  of  the  right  auriculo-ventric- 
xilar  orifice,  the  pulmonary  second  sound  is  weak,  because  of  the  di- 
minished tension  in  the  pulmonary  artery,  unless  there  is  coincident 
obstruction  or  regurgitation  at  the  mitral  orifice,  which  causes  an 
accentuation  of  the  pulmonary  second  sound.  The  mechanical  effect 
of  the  lesions  on  the  right  side  is  immediate,  and  compensation  is 
possible  to  a  very  limited  extent.  Extreme  venous  stasis  soon  occurs, 
with  the  attendant  symptoms  of  hepatic  disturbance,  ascites,  albumi- 
nuria, general  dropsy.  The  jjrognosis  is  therefore  unfavorable.  The 
diagnosis  is  difiicult  because  of  the  coexistent  mitral  lesions,  but  the 
lesions  of  the  right  auriculo-ventricular  orifice  are  established  by  the 
determination  of  these  physical  signs:  a  well-marked,  true  venous 
pulsation  of  the  neck  ;  a  systolic  murmur,  audible  with  the  greatest 
intensity  at  the  junction  of  the  intercostal  space  between  the  fourth 
and  fifth  rib  with  the  right  border  of  the  sternum,  and  a  weak,  pul- 
monary second  sound. 

AFFECTIONS  OF  THE  PULMONARY  VALVES  AND  ORIFICE.— 

These  may  be  congenital  or  acquired.  When  acquired  they  are  pro- 
duced by  endocarditis,  or  are  due  to  calcareous  deposition  and  athe- 
romatous degeneration,  but  acquired  changes  are  extremely  rare.  The 
results  of  stenosis  and  insufficiency  are  the  same,  and  consist  of  dilata- 
tion of  the  cavity  and  hyperti'ophy,  leading  to  insufficiency  of  the 
tricuspid.  In  insufficiency  of  the  pulmonary  valves  the  resulting  con- 
ditions are  the  same  as  in  the  corresponding  change  at  the  aortic  ori- 
fice. The  pulmonary  artery  and  its  divisions  undergo  dilatation,  the 
intima  becomes  the  seat  of  the  nutritive  changes  already  described, 
and  lobular  pneumonia  and  haemorrhagic  infarctions  occur  in  the 
lungs.  The  rational  signs  are  dyspnoea,  deficient  aeration  of  the 
blood  and  cyanosis,  distention  of  the  superficial  vessels,  dropsy,  pal- 
pitation of  the  heart,  prsecordial  oppression,  sudden  attacks  of  suffo- 


278  DISEASES   OF   THE   HEART. 

cative  feeling,  with  prsecordial  pain  and  intense  anxiety,  etc.  The 
physical  signs  are  those  of  enlargement  of  the  right  cavities,  a  loud 
diastolic  murmur  heard  with  great  intensity  at  the  left  border  of  the 
sternum  and  the  upper  margin  of  the  third  rib,  and  propagated  toward 
the  middle  of  the  sternum,  opposite  the  fourth  rib  and  downward, 
and  is  lost  going  toward  and  over  the  great  vessels  at  the  base.  There 
may  be  also  a  systolic  murmur.  These  symptoms  only  occur  when 
the  compensation  is  ruptured,  for  the  hypertrophy  of  the  ventricle 
walls  and  the  dilatation  of  the  cavity  compensate  very  fully  for  the 
mischief  done. 

Stenosis  is  a  more  important  condition  than  insufficiency,  but  it  is 
congenital  stenosis  with  which  we  have  to  deal  chiefly,  the  acquired 
condition  being  exceedingly  rare.  In  congenital  stenosis  the  changes 
consist  in  constriction  of  the  pulmonary  artery,  unclosed  foramen  ovale, 
unclosed  ductus  Botalli,  stricture  at  the  ductus  Botalli,  with  hypertro- 
phy of  the  right  cavities.  The  importance  of  these  congenital  defects, 
besides  the  damage  to  the  heart,  consists  in  the  frequent  association  of 
these  anatomical  anomalies  with  tuberculosis  of  the  lungs.  The  right 
ventricle  enlarges  to  a  remarkable  extent,  the  walls  attaining  in  thick- 
ness to  the  dimensions  almost  of  the  left.  The  result  is,  there  are  pres- 
ent the  physical  signs  of  hypertrophy  of  the  right  ventricle — an  in- 
creased area  of  cardiac  dullness  to  the  right ;  a  blowing,  systolic  mur- 
mur, audible  in  the  pulmonary  area,  and  propagated  not  toward  the 
base  and  great  vessels,  but  somewhat  to  the  left  and  a  little  down- 
ward, the  point  of  greatest  intensity  being  the  junction  of  the  third 
rib,  upper  border,  with  the  left  border  of  the  sternum  ;  weak  or  inau- 
dible second  sound.  The  rational  symptoms  correspond  to  the  ana- 
tomical conditions.  The  compensation  effected  by  dilatation  and  hy- 
pertrophy of  the  right  ventricle  suffices  to  maintain  a  condition  of 
comparative  comfort,  but  unusual  physical  exercise,  obstructive  pul- 
monary diseases,  and  other  causes  bring  about  a  rupture  of  the  com- 
pensation, when  there  ensue  difficulty  of  breathing,  cough,  cyanosis 
that  may  be  very  intense,  but  general  dropsy  and  albuminuria  occur 
only  when  the  right  ventricular  wall  weakens  by  myocarditis. 

The  duration  of  these  cases  of  congenital  defects  in  the  structure 
of  the  heart  varies  with  the  degree  of  deformity  and  the  circumstances 
in  life.  The  compensation  may  be  so  perfect  that  the  heart  is  equal  to 
the  needs  of  a  quiet  existence,  and  comparative  comfort  may  be  en- 
joyed by  youths  who  possess  even  a  considerable  degree  of  cyanosis. 
But  the  degree  of  cyanosis  is  usually  a  measure  of  the  success  of  the 
efforts  at  compensation.  The  subjects  of  congenital  pulmonary  stenosis 
are  otherwise  imperfect  in  organization — they  are  comparatively  weak, 
develop  slowly,  have  soft,  flabby  muscles,  bones  do  not  unite,  and  the 
nutrition  continues  poor.  Beside  the  cyanosis,  which  is  usually  most 
strongly  marked  in  the  extremities,  they  have  cold  hands  and  feet,  and 


VALVULAR   LESIONS.  279 

possess  but  little  endurance  of  cold,  are  subject  to  asthmatic  attacks, 
to  giddiness  and  vertigo,  to  epileptoid  attacks,  etc.  The  duration  of 
life  in  these  congenital  cases  varies  from  a  few  months  to  twenty  or 
thirty  years. 

Treatment. — In  a  clinical  lecture  recently  published,*  which  is 
marked  by  that  clinical  acumen  and  power  of  accurate  expression  char- 
acteristic of  the  author,  Flint  emphasizes  the  necessity  for  caution  in 
the  expression  of  opinion  to  the  subjects  of  cardiac  mischief  ;  the  im- 
portance of  recognizing  the  fact  that  some  murmurs  have  no  patho- 
logical nor  clinical  significance  ;  the  good  results  obtained  from  the 
treatment  of  associated  morbid  states  in  cases  of  undoubted  valvular 
disease  ;  and,  finally,  the  striking  relief  derived  from  the  timely  use  of 
"digitalis  and  active  hydragogue  purgation  repeated  from  time  to 
time."  Any  one  having  clinical  experience  will  fully  and  entirely 
agree  with  the  distinguished  professor  in  these  observations.  When 
the  mischief  done  to  the  heart  is  recent,  and  the  newly  formed  con- 
nective tissue  is  contracting,  it  is  highly  important,  as  Fothergill  f  has 
pointed  out,  to  give  the  heart  "physiological  rest,"  to  enable  the  dam- 
age to  the  valves  to  be  repaired  as  completely  as  can  be  effected.  The 
rest  is  best  secured  by  maintaining  the  recumbent  posture  much  of  the 
time  during  the  period  of  convalescence,  by  the  careful  administration 
of  veratrum  viride,  to  keep  the  revolutions  of  the  heart  at  about  fifty 
to  sijfty  per  minute,  and  by  iron  and  a  suitable  diet  to  improve  the 
quality  of  the  blood.  When  compensation  is  effected  and  the  heart  is 
equal  to  the  obstacles,  no  medicinal  treatment  is  necessary.  Every 
effort  must  be  directed  to  the  maintenance  of  the  compensation,  by 
quietude  of  mind  and  body,  and  by  avoidance  of  all  causes  of  diseases. 
Active  exercise,  climbing  mountains,  running  up  stairways,  lifting,  and 
every  kind  of  physical  exertion  involving  heart-strain,  must  be  avoided; 
nevertheless,  daily  open-air  exercise  and  exposure  to  sunshine  are  ne- 
cessary to  maintain  health  at  the  proper  standard — for,  if  the  blood  is 
impoverished  by  an  in-door  life,  and  the  want  of  appetite  and  imper- 
fect sleep,  which  are  necessary  results,  the  rupture  of  the  compensation 
must  then  take  place.  In  the  natural  course  of  events  in  valvular  af- 
fections, the  nutritive  alterations  which  occur  in  the  tunics  of  the  ves- 
sels and  in  the  heart-muscles  ultimately  effect  a  rupture  of  the  com- 
pensation. Anaemia  not  only  hastens  the  pathological  processes  taking 
place  in  the  vessels  and  in  the  heart,  but  it  actually  inaugurates  similar 
changes.  It  is,  therefore,  a  measure  of  the  highest  importance  to  keep 
the  appetite,  digestion,  and  blood-making  process,  in  the  most  efficient 
state.  Moderate  exercise  in  the  open  air  daily  must  be  enjoined  in 
these  cases,  while  fatigue  and  strong  exertion  of  any  kind  are  avoided. 

*  The  "  Medical  News  and  Abstract,"  January  1,  1880. 
f  "Diseases  of  the  Heart,"  second  edition. 


280  DISEASES   OF   THE   HEART. 

When  the  heart  is  behaving  badly  in  consequence  of  the  anaemic  con- 
dition, the  organ  is  relieved  by  attention  to  the  nutrition.  Unless, 
therefore,  under  such  circumstances  there  is  plain  need  of  digitalis,  it 
should  be  avoided,  for  this  agent  disturbs  the  stomach  and  interferes 
with  digestion.  "When,  in  women  especially,  the  compensation  is  not 
ruptured,  but  great  distress  is  experienced  from  anaemia  or  the  chlo- 
rotic  state,  the  indications  clearly  are  not  to  treat  the  heart,  but  those 
nutritive  disturbances  on  which  the  functional  troubles  depend.  When 
such  subjects  are  not  relieved  by  stomachic  tonics,  iron,  and  a  generous 
diet,  the  system  of  rest,  forced  feeding,  massage,  and  muscular  faradi- 
zation proposed  by  Weir  Mitchell  may  be  resorted  to  with  advantage. 
Besides  the  measures  necessary  to  prevent  or  overcome  anaemia,  the 
dietetic  management  requires  the  patient  with  compensated  valve- 
mischief  to  avoid  such  cardiac  stimulants  as  tea,  coffee,  tobacco,  and 
alcohol  in  any  form,  except  a  little  wine  allowed  at  dinner  provided  it 
improves  digestion.  The  choice  of  a  suitable  chalybeate  can  be  made 
from  a  long  list  of  preparations.  It  is  a  rule  that  combinations  of  iron 
with  a  mineral  acid  are  more  effective  and  often  better  borne  than 
the  milder  and  supposed  more  easily  assimilated  citrates,  tartrates,  and 
carbonates.  German  therapeutists  much  prescribe  the  ethereal  acetated 
tincture  of  their  pharmacopoeia.  The  tinctura  fei-ri  chloridi  is,  proba- 
bly, the  most  generally  useful  and  efficient  of  the  officinal  preparations. 
It  should  be  given  always  well  diluted  with  water  after  meals,  and 
should  be  taken  through  a  glass  tube  or  a  straw.  An  excellent  sto- 
machic tonic  is  tincture  of  nux  vomica — ten  drops  to  twenty — ter  in  die 
and  before  meals,  or  the  milder  tinctures  of  colomba  or  gentian  may 
be  preferred.  A  combination  of  great  value  in  these  cases  is  the  elixir 
of  the  phosphates  of  iron,  quinia,  and  strychnia  (Aitken).  The  nutri- 
tion in  cases  of  compensated  valvular  lesions  often  fails  slowly,  from 
the  gradual  congestion  of  the  liver  and  of  the  intestinal  mucous  mem- 
brane. The  digestion  is  slow  and  insufficient,  the  appetite  fails,  and 
the  absorption  of  aliment  is  seriously  intef  ered  with  by  the  hyperaemia 
and  distention  of  the  vessels.  Timely  recognition  of  this  state  and 
the  use  of  appropriate  means  will  prevent  serious  trouble.  Excellent 
remedies  are  iridin  and  euonymin  ;  they  are  stomachic  tonics,  and,  in 
sufficient  quantity,  powerfully  stimulate  the  hepatic  functions  and  de- 
plete the  portal  system.  The  treatment  should  be  commenced  by  free 
action  of  the  intestines  procured  by  these  agents  or  corresponding  ones. 
Then  stomachic  tonics,  chalybeates,  and  digestives,  as  pepsin  and  lac- 
topeptine,  are  indicated.  The  kidneys  should  be  kept  active,  and  this 
is  best  accomplished  by  the  simultaneous  but  not  conjoint  use  of  a 
chalybeate  and  a  diuretic,  as  tincture  of  iron  and  solution  of  bitartrate 
of  potassa — the  iron  to  be  taken  after  meals,  and  the  potassa  solution 
to  be  drunk  freely  between  meals.  An  excellent  method  of  managing 
these  cases,  when  a  rupture  of  the  compensation  is  threatened,  is  to 


VALVULAR   LESIONS.  281 

give  two  or  three  times  a  week  some  efficient  doses  of  iridin  or  euony- 
min,  and  to  prescribe  iron,  quinia,  and  digitalis  in  pill-form — a  half 
grain  of  ferrum  redactum,  three  grains  of  quinia,  and  a  gi*ain  of  digi- 
talis in  a  pill  three  times  a  day.  If  the  stomach  is  doing  fairly  good 
work,  the  best  results  may  be  expected  from  this  combination.  The 
practitioner  is  usually  consulted  when  the  failure  of  the  heart,  dyspnoea, 
cough,  anaemia,  albuminuria,  and  beginning  dropsy,  announce  the  rup- 
ture of  the  compensation.  The  principles  of  treatment  differ  some- 
what, according  to  the  seat  and  character  of  the  lesion  and  the  condi- 
tion of  the  system.  As  the  ultimate  effect  of  all  cases  of  valvular  dis- 
ease of  the  heart  is  to  cause  ischnemia  of  the  arterial  system  and  stasis 
of  the  venous,  a  general  method  of  therapy  may  be  first  developed  and 
the  special  indications  pointed  out  subsequently.  The  remedy  which, 
above  all  others,  opposes  the  condition  of  the  vascular  system  in  val- 
vular disease  of  the  heart  is  digitalis.  In  prescribing  this  agent  there 
are  several  points  to  be  carefully  considered.  Is  the  digitalis  of  two 
years'  growth  ?  Is  it  English  or  German  ?  Is  it  wild  or  cultivated  ? 
The  second-year  plant  contains  more  of  the  active  principle  ;  the  pro- 
duction of  this  continent  seems  inferior  to  that  of  English  or  German 
sources  ;  the  wild  digitalis  is  more  active  than  the  domesticated.  For 
the  effect  on  the  circulation  and  on  the  kidneys,  the  officinal  infusion  is 
to  be  preferred  to  the  other  preparations,  but  the  infusion  is  only  ser- 
viceable when  it  is  made  from  the  proper  digitalis.  It  must  be  given  in 
sufficient  quantity  to  produce  its  physiological  effects — to  diminish  the 
number  but  increase  the  force  of  the  pulsations  ;  to  raise  the  tension 
of  the  vessels  ;  to  increase  the  urinary  discharge.  The  higher  the 
tension  at  the  periphery,  the  more  decided  the  recoil,  and  consequently 
the  better  filled  is  the  coronary  artery,  which  includes  a  more  active 
and  healthy  state  of  nutrition  of  the  cardiac  muscle.  The  higher  ten- 
sion of  the  vessel  means  an  arrest  of  the  outflow  of  the  serum  and  more 
active  absorption.  When  the  compensation  is  ruptured,  the  digestive 
organs  suffer  and  the  blood-making  is  inefficient.  Excretion  by  the 
liver  is  hindered,  and  the  waste  of  albumen  through  the  kidneys  lessens 
rapidly  the  amount  of  this  important  constituent  in  the  blood.  The 
poverty  of  the  blood  reacts,  again,  on  the  circulation  through  the  heart. 
When,  therefore,  the  necessity  for  digitalis  arises,  the  demand  for  iron 
and  bitter  tonics  (quinia)  must  be  heeded  also.  Experience  has  abun- 
dantly demonstrated  that  the  effects  of  digitalis  are  more  decided  and 
more  lasting  when  iron  and  quinia  are  given  at  the  same  time.  A 
tablespoonf ul  of  the  officinal  infusion  three  times  a  day  until  the  char- 
acteristic effects  are  produced,  and  then  twice  a  day,  is  the  amount 
usually  required  and  that  can  be  borne.  As  its  action  is  slow,  frequent 
repetition  of  the  dose  may  cause  serious  symptoms.  If  large  doses  are 
taken,  and  if  the  pulse  is  much  reduced,  the  patient  should  maintain 
a  fixed  position — what  position  soever  it  may  be — and  not  change  it 


382  DISEASES   OF  THE   HEART. 

suddenly.  Especially  should  lie  not  rise  suddenly  from  the  recumbent 
posture,  for  under  these  circumstances  the  pulse  becomes  rapid  and 
feeble  and  the  surface  cyanosed.  When  headache,  dizziness,  disturb- 
ances of  vision,  vibration  of  external  objects,  and  anxiety  are  produced, 
the  dose  must  be  at  once  reduced  or  discontinued.  It  should  also 
not  be  forgotten  that  digitalis  continued  in  large  doses  aifects  the 
motor  power  of  the  heart  ultimately,  by  exhausting  the  irritability  of 
the  ganglia,  when  the  action  becomes  rapid,  weak,  and  irregular.  It 
is  good  practice,  during  the  long-continued  use  of  digitalis,  to  suspend 
it  for  a  few  days  at  a  time.  If  it  can  not  be  borne,  cimicifuga  may  be 
substituted — a  half  to  a  drachm  of  the  fluid  extract  three  times  a  day, 
Suflicient  attention  has  not  been  given  to  the  utility  of  cimicifuga  as  a 
cardiac  tonic  and  substitute  for  digitalis.  Of  the  mineral  tonics,  no 
one  is  so  serviceable  as  the  acetate  of  lead.  When  there  is  much  op- 
pression of  breathing,  the  patient  unable  to  lie  down,  and  becoming 
exhausted  from  loss  of  sleep,  no  remedy  is  so  valuable  as  morj)hia 
hypodermatically.  It  affords  surprising  relief  to  the  distressing  symp- 
toms, improves  remarkably  the  driving  power  of  the  heart,  causes  free 
diaphoresis,  and  gives  time  for  the  action  of  the  other  remedies.  We 
owe  this  important  suggestion  to  Dr.  Clifford  Allbutt,  of  England. 
From  the  ^^^  to  ^  of  a  grain  of  morphia,  according  to  the  character  and 
susceptibility  of  the  patient,  should  be  given.  Next  to  the  remedies 
for  the  heart,  in  importance,  are  the  hydragogue  cathartics.  The  great- 
est relief  is  afforded  by  draining  off  fluid  from  the  intestinal  mucous 
membrane.  Euonymin  and  iridin  have  already  been  mentioned,  but 
more  powerful  remedies  are  necessary  when  there  is  general  dropsy. 
One  of  the  most  useful  and  efficient  of  these  is  the  compound  jalap 
powder.  As  it  is  important  not  to  interfere  with  the  digestion,  this 
remedy  should  be  administered  in  the  early  morning.  If  not  sufii- 
ciently  active,  podophyllin  may  be  added,  or,  this  failing,  elaterium 
may  be  substituted.  Free  transpiration  by  the  skin  should  be  main- 
tained. This  is  best  effected  by  the  vapor-bath.  The  mistake  must 
not  be  made  of  attempting  to  act  on  the  skin  and  kidneys  at  the  same 
time.  When  digitalis  is  being  taken,  and  bitartrate  of  potassa  or  other 
diuretics,  the  skin  must  not  be  excited  at  the  same  time  ;  on  the  other 
hand,  free  purgation  assists  the  action  of  diuretics.  When  digitalis 
can  not  be  borne  by  the  stomach,  it  may  act  quite  efiiciently  by  exter- 
nal application  to  the  abdomen  or  back  :  some  leaves  inclosed  in  a 
muslin  bag  are  steeped  in  warm  water,  and  kept  applied  for  several 
hours.  When  the  vapor-bath  can  not  be  used,  a  good  substitute  is  a 
warm,  wet  pack  covered  with  blankets.  Remarkable  benefit  has  been 
obtained  from  the  treatment  by  compressed  air,  and  by  the  inhalation 
of  oxygen.  The  compressed-air  treatment  diminishes  the  tension  in 
the  venous,  and  elevates  it  in  the  aortic  system,  and  also  gives  relief 
by  contributing  to  the  oxygenation  of  the  blood.     Oxygen  merely  acts 


HEART-CLOTS.  283 

in  the  latter  mode,  and  often  affords  great  comfort  when  there  are 
paroxysmal  attacks  of  dyspncea.  There  are  some  limitations  to  the  use 
of  digitalis  in  ruptured  compensation  with  its  direful  results.  It  can 
not  be  borne  at  all  by  some  subjects.  It  is  contraindicated  in  aortic 
stenosis,  and  may  be  dangerous  in  large  doses.  When  there  is  mitral 
insufficiency,  as  well  as  aortic  stenosis,  digitalis  may  be  given,  but  only 
in  small  doses,  with  a  view  to  its  diuretic  action.  Again,  digitalis  is 
of  doubtful  utility  if  not  positively  contraindicated  in  fatty  heart,  and 
consequently  in  cases  of  dropsy,  from  dilatation  and  insufficiency  due 
to  fatty  degeneration. 

HEART-CLOTS. 

Definition. — By  the  term  heart-dot  is  meant  a  mass  of  fibrin  or 
of  coagulated  blood  found  in  one  or  more  of  the  cavities  of  the  heart. 
They  are  divisible  into  three  varieties  :  First,  translucent  masses  of 
fibrin,  soft,  yellowish,  and  full  of  serum,  loosely  attached  to  the 
chordae  tendinse,  trabecule,  or  other  projecting  parts  ;  second,  large, 
loose,  black  coagula  occupying  the  right  ventricle  or  auricle,  and  ex- 
tending into  the  pulmonary  artery  or  vense  cavae  ;  third,  coagula  of 
variable  size,  attached  to  projecting  parts,  found  in  all  cavities,  but 
chiefly  in  the  left  ventricle,  and  consisting  of  coagula  containing  a 
puriform -looking  fluid  in  their  interior.  The  first  variety  is  not 
pathological,  is  formed  during  the  death-agony  or  after  death,  and 
is  found  in  the  subjects  of  chronic  wasting  disease.  The  second  va- 
riety may  or  may  not  be  pathological,  and  stand  in  a  genetic  relation 
to  the  suspension  of  the  cardiac  movements.  The  third  variety  is 
always  pathological. 

Causes. — The  occurrence  of  these  clots  is  not  affected  by  sex,  but 
they  are  more  frequent  at  the  middle  period  than  at  the  extremes  of 
life  (Bristowe*).  There  are  two  leading  factors  in  their  causation — 
a  condition  of  the  blood  ;  disease  of  the  heart  itself.  In  many  diseases 
the  fibrinogenous  substance  seems  to  be  greatly  increased,  and  thus  a 
state  of  ready  coagulability  is  induced.  If,  under  these  circumstances, 
the  coagulation  of  the  blood  is  favored  by  a  slow  and  feeble  action  of 
the  heart,  a  slight  cause  suffices  to  determine  it.  The  actual  deter- 
mining cause  is  disease  of  the  heart  itself,  roughness  of  some  project- 
ing part,  or  fibrinous  concretion  deposited  on  such  rough  surface. f 

Pathological  Anatomy. — Clots  ai-e  found  in  all  the  cavities  of  the 
heart,  but  most  frequently  in  the  left  ventricle  and  least  frequently  in 
the  left  auricle  (Bristowe).  They  form  in  by-places,  and  are  entangled 
in  the  rough  surfaces  and  inequalities.  The  appearance  of  the  clots 
differs  according  to  the  circumstances  of  their  formation.     Leaving 

*  "  Pathological  Society's  Transactions,"  vol.  xiv,  p.  71. 
f  Ibid.,  cases  by  Dr.  J.  W.  Ogle. 


284:  DISEASES   OF   THE   HEART. 

out  of  consideration  tlie  masses  of  fibrin,  which  have  no  pathological 
import,  the  two  other  varieties  differ  in  consequence  of  the  changes 
wrought  by  age.  The  second  variety  mentioned  above  consists  of  a 
large,  black,  rather  loose  venous  coagulum,  which  fills  one  or  the  other 
cavity  of  the  right  side  and  projects  into  the  annexed  vessel,  which 
may  be  completely  filled  by  it.  Such  a  clot,  we  may  suppose,  is  some- 
times the  cause  of  death  after  post-partum  haemorrhage,  or  such  as  Sir 
Joseph  Fayrer  describes  *  as  forming  and  causing  sudden  death  after 
surgical  operations.  After  profuse  hsemorrhage  of  this  kind,  the  pro- 
pelling power  of  the  right  ventricle  is  so  feeble  that  coagulation  may 
readily  ensue.  The  shock  of  a  surgical  operation  may  induce  such 
slowness  and  weakness  as  a  severe  hsemorrhage,  and  result  in  the  same 
accident.  In  the  third  variety  the  clot  has  undergone  transformations 
due  to  age.  It  is  firm,  tough,  grayish,  yellowish,  and  brownish  in 
strata,  or  variously  intermingled,  and  attached  to  the  columnse  carnese, 
chordae  tendinse,  or  other  parts.  It  usually  contains  in  the  interior, 
in  a  pseudo-cyst,  a  quantity  of  thick  fluid  having  a  "  grumous "  or 
"puriform"  appearance,  and  consisting  of  the  fibrin,  red  and  white 
corpuscles,  undergoing  the  transformation  usual  to  blood  under  these 
circumstances,  f  These  clots  are  in  position  for  a  long  time,  often. 
Rarely  are  they  found  in  a  sound  heart,  and  usually  the  changes  of 
endocarditis  have  taken  place,  the  coagulation  of  the  blood  being  in- 
duced by  roughening  and  exudation  of  the  membrane. 

Symptoms. — Nothing  can  be  more  indefinite  than  the  symptoma- 
tology of  heart-clots.  Nevertheless,  we  may  make  an  attempt  to  define, 
from  recorded  cases  and  from  observation,  the  character  of  the  dis- 
turbances of  function  caused  by  them.  There  are  two  distinct  groups 
of  symptoms  belonging  to  the  two  forms  of  clot.  After  post-partum 
haemorrhage,  or  after  a  surgical  operation,  or  during  the  course  of 
some  septic  disease,  there  suddenly  comes  on  an  extreme  oppression  of 
breathing,  wild  restlessness,  beating  about  the  bed  and  crying  out  for 
air,  deep  cyanosis,  a  fluttering  heart  without  pulse  at  the  wrists,  which 
stops  in  a  few  minutes  ;  the  patient  falls  back,  the  agitation  ceases, 
but  then  a  general  convulsion  may  occur,  and  all  is  over,  or  death 
occurs  quietly  without  any  convulsive  movement.  In  the  other  variety 
the  symptoms  develop  more  slowly,  and  may  extend  over  several  weeks. 
The  earliest  symptoms  are  irregularity  in  the  heart-movements,  indis- 
tinctness of  the  murmurs,  difficulty  of  breathing,  anxiety,  oppression, 
cyanosis.  The  action  of  the  heart  becomes  more  and  more  feeble,  the 
sounds  run  into  each  other  and  are  dull  and  confused,  the  difficulty  of 
breathing  continues,  moist  rales  appear  all  over  the  chest  from  oedema 

*  "  The  Medical  Times  and  Gazette,"  vol.  i,  1873,  p.  58;  also  "Pathological  Society's 
Transactions,"  vol.  xxvii,  p.  70. 

f  Cases  by  Dr.  J.  W.  Ogle,  "  Pathological  Society's  Transactions,"  vol.  xiv,  p.  65, 
et  seq. 


PALPITATION   OF   THE   HEART.  285 

of  the  lungs  ;  the  cyanosis  deepens  ;  dropsy  comes  on  ;  stupor  passing 
into  unconsciousness,  and  convulsions  end  the  scene. 

In  most  of  the  cases  recorded  by  Ogle,  the  urine  was  albuminous  ; 
there  were  lesions  of  the  lungs,  and  effusion  into  the  thoracic  cavity. 
While  the  recorded  symptoms  are  closely  similar  to  the  account  given 
above,  the  state  of  the  heart  as  to  rhythm  and  the  character  of  the 
sounds  differ  among  themselves,  and  agree  in  part  only  with  the 
above  description.  The  duration  of  these  cases  ranged  from  a  few 
days  to  six  weeks,  and  the  symptoms  during  that  time  seemed  to  de- 
pend on  the  presence  of  the  clot  found  j^ost  mortem. 

Treatment. — Notwithstanding  the  uncertainty  which  must  attend 
the  diagnosis  in  these  cases,  which  at  its  best  must  be  a  fortunate 
guess,  some  details  of  treatment  are  necessary.  The  treatment  by 
frequent  small  doses  of  ammonium  carbonate  offers  the  best  prospect 
of  relief.  In  the  cases  which  occur  suddenly,  and  immediately  extin- 
guish life,  the  intra- venous  injection  of  ammonia  should  be  practiced. 
This  method  consists  in  the  injection  into  any  vein — in  this  case,  the 
jugular — of  one  part  of  aqua  ammonise  to  two  parts  of  water,  by  an  hy- 
podermic syringe.  Of  course,  precautions  must,  be  taken  to  avoid  the 
introduction  of  air  or  any  foreign  body.  It  has  been  abundantly 
demonstrated  that  this  intra-venous  injection  of  ammonia  is  entirely 
safe.  In  the  less  acute  cases,  there  is  a  small  prospect  of  success  from 
the  persistent  use  of  the  ammonia.  The  action  of  the  heart  must  be 
maintained  by  the  judicious  use  of  digitalis  and  alcoholic  stimulants. 

PALPITATION    OF    THE    HEART. 

Deflnition. — By  the  term  ^^oXp^^CLt^on  of  the  heart  is  meant  a  func- 
tional disturbance  of  the  organ,  characterized  by  increased  rapidity  of 
movement,  with  more  or  less  irregularity  of  rhythm. 

Causes. — The  heart  possesses  a  power  of  independent  motion  ;  but 
as  this  motor  apparatus  is  not  sufficient  to  keep  up  the  action  of  the 
organ,  it  receives  accessions  of  force  from  the  great  centers.  To 
maintain  the  movement  at  a  uniform  rate,  there  is  a  regulator  appara- 
tus, designed  to  prevent  overaction,  or  "  to  inhibit."  Besides  this  mech- 
anism for  evolving  force,  and  applying  it  so  as  to  produce  uniform 
results,  the  action  is  affected  by  the  state  of  the  vessels,  by  the  den- 
sity of  the  blood,  by  the  movements  of  the  respiratory  organs,  by  the 
activity  of  the  organic  functions  in  general,  and  by  the  functions  of  ani- 
mal life.  Accordingly,  to  maintain  the  action  of  the  heart,  there  are — 
1.  A  motor  apparatus — rhythmically  discharging  motor  ganglia — situ- 
ated in  the  substance  of  the  heart.  2.  Excitors  of  activity,  branches  from 
the  cervical  sympathetic,  and  also  from  the  spinal  cord,  irritation  of 
which  increases  the  movements  of  the  heart.  To  regulate  the  move- 
ments of  the  heart,  there  are — 1.  The  pneumogastric,  irritation  of  which 


286  DISEASES   OF   THE   HEART. 

may  arrest  the  heart  in  the  diastole.  2.  The  depressor  nerve  of  Lud- 
wig,  which  acts  by  dilating  the  blood-vessels.  The  fibers  of  the  sym- 
pathetic, dilator,  and  constrictor,  aifect  the  work  of  the  heart  by 
increasing  or  lessening  the  tension  at  the  periphery.  When  the  pe- 
ripheral vessels  are  dilated,  the  work  to  be  done  by  the  heart  lessens, 
and  hence  the  contractions  are  less  numerous  and  forcible,  and  vice 
versa. 

The  mechanism  by  which  the  action  of  the  heart  is  kept  at  a  uni- 
form rate  may  be  disturbed  by  a  variety  of  causes  :  by  muscular 
exercise  ;  breathing  rarefied  air,  as  in  the  ascent  of  mountains  ;  by 
mechanical  interference  with  the  movements  of  the  organ,  as  thoracic 
effusions,  tumors  of  the  mediastinum,  flatulent  distention  of  the  stom- 
ach, atheroma  of  the  arterial  system  generally,  etc.  Moral  and  emo- 
tional causes,  as  grief,  hope,  anxiety,  fear,  excessive  mental  effort,  etc., 
increase  the  action  of  the  heart.  Various  reflex  troubles  have  the 
same  effect — as  affections  of  the  nervous  system,  reacting  on  the  ner- 
vous apparatus  of  the  heart — such  as  uterine  disease,  gastralgia,  worms 
in  the  intestinal  canal,*  etc.  The  cardiac  ganglia  are  rendered  irritable 
by  the  excessive  use  of  tea,  coffee,  tobacco,  spirits,  etc.  The  excitor 
apparatus  of  the  sympathetic  may  be  the  seat  of  a  disturbance,  as  in 
Grave's  disease,  etc. 

Symptoms. — There  may  or  may  not  be,  previous  to  the  attacks  of 
palpitation,  any  symptom  of  trouble  in  the  heart.  When  such  prelim- 
inary symptoms  are  felt,  they  consist  of  a  vague  sense  of  uneasiness, 
prsecordial  oppression,  or  dull  pain.  There  is  no  fixed  period  for  the 
attacks,  unless  excited  by  some  habit  or  custom,  as  eating,  smoking, 
etc. ;  neither  have  they  any  special  duration,  but  may  last  from  a  few 
minutes  to  some  hours,  or  a  day.  The  attack  consists  of  a  rapid  and 
tumultuous  beating  of  the  heart ;  dyspnoea,  anxiety,  and  an  hysterical 
sense  of  choking  accompany  the  beating  ;  the  heart  seems  almost  to 
turn  over,  to  rise  up  into  the  throat ;  the  recumbent  posture  can  not 
usually  be  borne,  esiDecially  lying  on  the  left  side,  and  the  sitting  pos- 
ture, leaning  somewhat  forward,  is  the  most  comfortable  position  ; 
there  are  also  experienced  more  or  less  vertigo,  faintness,  flashes  of 
light,  coldness  of  the  surface  with  cold  sweating  and  a  very  weak 
pulse,  or  it  may  be  the  surface  is  warm  and  perspiring,  the  pulse  full 
and  strong.  The  face  may  be  pale  or  flushed,  but  is  always  expressive 
of  anxiety  ;  speech  is  difiicult,  or  is  arrested.  The  physical  explora- 
tion, if  no  cardiac  lesion  exist,  is  merely  negative.  The  movement,  if 
very  rapid,  can  not  be  separated  into  its  component  parts.  Examina- 
tion must  be  made,  in  the  interval  of  the  seizures,  to  ascertain  the  real 
condition  of  the  heart.     The  duration  of  the  attacks,  as  already  stated, 

*  Case  of  Dr.  Cotton  ("The  British  Medical  Journal,"  June,  ISG*?),  in  which  the  pul- 
sations were  240  per  minute,  and  ceased  on  the  evacuation  of  a  tape-worm. 


ARTERITIS.  287 

is  very  variable.  The  beating  may  subside  in  a  few  minutes,  or  sev- 
eral hours  may  be  occupied  in  returning  to  the  normal.  At  the  con- 
clusion of  the  paroxysm,  a  quantity  of  pale,  limpid  urine  is  usually 
passed,  and  there  is  a  strong  sense  of  fatigue  and  exhaustion,  with  a 
tendency  to  sleep. 

Treatment. — Prophylaxis  is  important.  The  vice,  of  whatever 
kind,  on  w^hich  the  attacks  depend,  should  be  removed.  Tea,  coffee, 
and  spirit  drinking  must  be  given  up  ;  errors  of  digestion,  reflex  dis- 
turbances, and  curable  diseases  must  be  corrected  or  cured.  The  hy- 
giene of  the  individual  must  be  carefully  investigated,  and  sources  of 
disturbance  be  put  aside.  The  general  health  must  be  maintained  at 
the  highest  point  of  efficiency.  In  the  absence  of  any  explanation  of 
the  paroxysms,  the  presence  of  a  tape-worm  may  be  suspected.  For 
the  immediate  relief  of  the  paroxysm,  there  is  no  remedy  so  efficient 
as  the  hypodermatic  injection  of  morphia.  If  the  surface  is  pale  and 
the  extreme  vessels  contracted,  inhalation  of  nitrite  of  amyl  (two  or 
three  drops)  affords  prompt  relief.  The  inhalation  of  ether  is  also 
effective.  All  narcotic  agents  must  be  used  with  caution,  because  of 
the  certainty,  if  the  attacks  are  frequent,  that  the  habit  of  their  abuse 
will  be  formed.  The  application  of  cold,  in  the  form  of  an  ice-bag  to 
the  jDrsecordial  space,  is  an  effective  means  of  quieting  the  heart.  The 
galvanic  current,  from  ten  to  thirty  or  forty  elements,  passed  through 
the  pneumogastric  and  cervical  ganglia  of  the  sympathetic,  often  gives 
great  relief.  If  there  is  no  cardiac  disease,  chloral  is  an  efficient  quiet- 
ing agent,  and  the  bromides  may  also  be  given  with  good  results. 


DISEASES   OF   THE  BLOOD-VESSELS. 


ARTERITIS— INFLAMMATION   OF  THE   ARTERIES. 

Definition. — The  acute  form  of  arteritis  is  uncommon,  and  is  rather 
a  surgical  than  a  medical  topic.  Chronic  arteritis,  on  the  other  hand, 
is  not  only  a  common  but  it  is  an  extremely  important  disease.  It 
has  received  various  designations,  as  endarteritis,  atheromatous  arte- 
ritis, arterial  sclerosis,  arteritis  deformans,  etc.,  intended  to  indicate 
the  nature  of  the  change  undergone  by  the  vessel. 

Causes. — It  is  extremely  rare  before  forty,  and  frequent  after  fifty. 
Men  are  probably  more  liable  to  it  than  women,  but  there  is  slight 
difference  as  reo-ards  sex.     Various  cachexise  seem  to  hasten  its  devel- 


288  DISEASES   OF -THE   BLOOD-VESSELS. 

opment.  A  fatty  change  occurs  in  the  intima  during  the  course  of 
severe  and  prolonged  anaemia.  Chronic  alcoholism,  the  poison  of  lead, 
gout,  rheumatism,  syphilis,  etc.,  are  supposed  to  be  influential  in  devel- 
oping the  disease  at  an  early  period.  Functional  strain,  in  accordance 
with  a  well-known  law,  tends  to  excite  arteritis  ;  hence  its  early  ap- 
pearance in  the  aorta.  Sometimes  aortitis  is  derived,  by  contiguity  of 
tissue,  from  endocarditis. 

Pathological  Anatomy. — The  initial  change  consists  in  a  prolifera- 
tion of  the  connective-tissue  corpuscles  of  the  intima  ;  the  young  cells 
crowd  the  space  between  the  lamellae,  and,  pushing  up  the  intima, 
form  a  projection  about  a  line  above  the  general  level.  This  abun- 
dant formation  of  new  cells  requires  an  amount  of  pabulum  which  can 
not  be  supplied,  and  hence  the  proliferating  cells  undergo  a  fatty  de- 
generation. While  this  process  is  going  on,  a  solution  of  the  basis 
substance  (the  connective-tissue  matrix)  takes  place.*  This  change 
appears  to  the  naked  eye  as  yellowish  or  yellowish- white  opaque  spots 
or  patches,  distributed  through  the  thickened  elevations  of  the  intima, 
which  become  soft  and  friable,  and  are  gradually  detached,  leaving  an 
abrasion,  or  "atheromatous  ulcer."  These  abrasions  may  be  coated 
with  masses  of  fibrin,  or  blood-clot  may  form  on  and  adhere  to  them. 
Coincidently  with  the  process  of  fatty  metamorphosis,  another  process, 
beginning  also  in  the  sclerosed  intima,  develops.  This  consists  in  a 
deposition  of  calcareous  material — the  lime  salts,  chiefly — in  the  basis 
substance  of  the  intima,  and  between  the  lamellae.  Plates  of  consid- 
erable size  are  thus  formed  in  the  aorta  ;  they  may  be  several  inches 
in  length,  and  of  a  curved  shape  corresponding  to  the  aortic  curve, 
and  may  extend  over  one  half,  even  more,  of  the  circumference  of  the 
vessel.  Their  rough  surfaces  project  through  the  innermost  lamella 
into  the  vascular  lumen.  These  two  processes  very  frequently  coin- 
cide. The  alterations  taking  place  in  chronic  arteritis  are  not  confined 
to  the  intima,  but  the  media  and  the  adventitia  also  participate.  The 
unstriped  muscular  fiber  undergoes  fatty  metamorphosis  and  calcifica- 
tion, or  disappears  by  simple  atrophy.  In  advanced  cases  the  adven- 
titia inflames,  becomes  infiltrated  with  cells,  or  undergoes  fibroid 
degeneration.  The  results  of  arteritis  are  very  important ;  when  the 
small  vessels  are  affected,  their  lumen  is  encroached  on  and  may  be 
entirely  obstructed,  or  a  large  number  affected  to  a  less  degree,  the 
amount  of  blood  passing  to  the  district  supplied  by  them  will  be  much 
reduced,  and  important  nutritive  alterations  must  occur.  The  changes 
in  the  tunics  of  the  vessels  especially  involve  their  elasticity,  and  they 
become  mere  rigid  cords,  through  which  the  blood  passes  in  jets.  The 
loss  of  the  power  of  elastic  recoil  exposes  them  to  injury  as  the  blood 
is  driven  through,  and  they  slowly  dilate  or  yield  in  places,  forming 

*  Rindfleisch,  op.  cit.,  p.  211,  d  seq. 


ARTERITIS.  289 

sacculi,  or  are  torn  outright.  The  increased  resistance  to  the  propulsion 
of  blood,  caused  by  these  changes  in  the  arteries,  leads  to  dilatation 
and  hypertrophy  of  the  left  ventricle.  Named  in  the  order  of  relative 
liability  to  arteritis  deformans,  are  the  aorta,  the  cerebral  arteries,  the 
coronary,  the  arteries  of  the  extremities,  and,  lastly,  the  arteries  dis- 
tributed to  the  organs  of  vegetative  life. 

Symptoms. — The  symptoms  are  obviously  of  a  very  diverse  charac- 
ter when  produced.  Nothing  is  more  usual  than  to  see  men  after  fifty 
with  extensive  atheroma,  without  a  single  symptom  referable  to  it. 
Nevertheless,  numerous  and  important  consequences  follow  arteritis  in 
some  situation^,  and  at  certain  stages  of  its  development.  Arteritis 
of  the  aorta,  and  the  cardiac  disturbances  due  to  it,  and  arteritis  of 
the  brain,  and  the  structural  alterations  produced  by  it,  are  the  same 
as  regards  the  arterial  change,  but  are  widely  different  in  respect  to 
the  symptomatology.  If  the  lumen  of  the  aorta  is  encroached  on, 
especially  if  very  great  narrowing  takes  place  at  the  bifurcation  of 
large  arteries,  or  if  extensive  arterial  districts  have  undergone  sclero- 
sis, the  work  of  the  heart  to  distribute  the  blood  is  so  much  increased 
that  the  organ  undergoes  hypertrophy.  This  change  is  indicated  by 
the  heaving  impulse,  by  an  extension  of  the  area  of  cardiac  dullness 
downward  and  to  the  left,  and  by  accentuation  of  the  second  sound. 
Murmurs,  due  to  regurgitation  or  stenosis,  or  both,  may  be  audible 
with  greatest  intensity  in  the  aortic  area,  when  an  extension  of  disease 
from  the  aorta  to  the  ■  semilunar  valves,  or  to  the  endocardium,  takes 
place.  Weakening  of  the  heart,  dyspnoea,  general  oedema,  may  finally 
occur  from  degenerative  changes  in  the  heart-muscle,  the  result  of 
atheroma  and  calcification  of  the  coronary  artery.  The  physical  signs, 
then,  of  hypertrophy,  from  the  causes  above  mentioned,  must  neces- 
sarily disappear  and  be  supplanted  by  others  when  the  aortic  valves 
and  the  cardiac  tissues  become  diseased.  Dilatation  of  the  ascending 
aorta  may  produce  a  pulsation  in  the  right  second  intercostal  space 
that  may  be  mistaken  for  aneurism,  and,  if  the  dilatation  be  consider- 
able, some  dullness  on  percussion  may  be  developed  in  the  same  posi- 
tion. The  changes  of  arteritis  deformans  may  be  studied  clinically  in 
some  superficially  placed  arteries,  as  the  radial  and  the  temporal ;  they 
are  rigid,  tortuous,  irregular  in  size,  and  may  be  rolled  under  the  skin 
like  whip-cord.  The  tortuosity  is  increased  during  the  systole,  and 
lessens  during  the  diastole,  and  the  pulse  is  delayed — firm  when  the 
calcification  is  beginning,  but  becoming  less  and  less  recognizable  as 
the  artery  degenerates  into  a  calcareous  tube.  The  loss  of  elasticity 
of  the  arterial  tunics  influences  the  sphygmographic  tracing,  which 
exhibits  the  same  features  as  in  albuminuria — rounded  summits,  ob- 
lique descent,  without  dicrotic  or  recoil  wave.  Advanced  endarte- 
ritis leads  to  disastrous  results  in  the  nutrition  of  peripheral  parts — 
the  fingers  and  toes.  In  consequence  of  the  diminished  supply  of 
19 


290  DISEASES  OF   THE  BLOOD-VESSELS. 

blood,  the  sensibility  is  low,  the  skin  bluish,  benumbed,  and  cold,  and 
the  least  injury  may  set  up  destructive  inflammation.  A  thrombus 
forming  in  the  principal  artery,  dry  gangrene  will  follow  in  the  parts 
below,  or  in  a  small  vessel  of  the  foot ;  a  single  toe,  or  several  toes, 
may  slough  off.  Even  more  serious  results  follow  endarteritis  of  the 
internal  vessels.  Thus,  as  has  been  pointed  out  in  the  article  on  gas- 
tric ulcer,  solution  of  the  mucous  membrane  and  the  subsequent  for- 
mation of  a  chronic  ulcer  may  have  its  origin  in  disease  of  an  artery 
and  thrombosis.  It  is  a  singular  fact  that,  although  the  arteries  of 
the  vegetative  organs  are  the  last  to  be  invaded  by  endarteritis,  yet 
it  occasionally  happens  that  a  small  part  of  an  artery  supplying  the 
gastric  mucous  membrane  is  the  seat  of  this  degeneration,  with  the 
disastrous  effect  above  mentioned.  But  the  arteries  of  the  brain  are 
much  more  widely  and  early  affected  by  endarteritis  than  of  any  ves- 
sels except  the  aorta,  and  indeed  this  morbid  process  may  begin  in  the 
brain.  The  dilatations  of  the  arterioles  and  small  arteries,  known  as 
miliary  aneurisms,  are  the  great  cause  of  cerebral  haemorrhage  ;  throm- 
boses of  the  capillaries  and  small  arteries  induce  local  softening ;  en- 
darteritis, without  interrupting  the  passage  of  the  blood  through  the 
lumen  of  the  vessels,  impedes  the  transference  of  the  nutritive  mate- 
rials to  the  tissue  of  the  brain,  with  the  result  of  serious  impairment 
of  the  nutrition  of  the  organ,  and  consequent  failure  of  mental  power, 
and  the  usual  objective  evidences  of  cerebral  mischief. 

Course,  Duration,  and  Termination. — The  course  of  endarteritis  is 
influenced  by  various  circumstances.  The  progress  of  the  change  is 
hastened  by  the  abuse  of  spirits,  and  by  such  cachexias  as  syphilis, 
rheumatism,  and  gout.  It  is  very  chronic,  and  its  duration  may  be 
measured  by  years.  As  has  been  pointed  out,  many  cases  exist  with- 
out causing  any  disturbance  ;  others  are  very  important  in  conse- 
quence of  the  lesions  invited  by  arteritis.  The  termination  is  a  ques- 
tion of  the  nature  of  the  secondary  lesions,  and  especially  of  the 
changes  in  the  cerebral  arteries.  There  is  more  danger  in  those  cases 
occurring  at  an  early  period  of  life.  For  example,  the  author  has 
seen  life  terminated  by  a  small  aneurism  of  the  basilar  artery,  when 
this  was  the  only  spot  where  endarteritis  existed. 

Treatment. — Although,  when  the  change  has  once  taken  place  in  an 
artery,  nothing  can  be  done  to  remove  it,  the  author  believes  that  the 
progress  may  be,  if  not  arrested,  at  least  retarded  by  proper  treatment. 
There  are  three  remedies  of  special  importance  in  this  disease  :  quinia, 
hypophosphite  or  lactophosphate  of  lime,  and  cod-liver  oil.  The 
phosphite  or  phosphate  of  lime,  and  the  cod-liver  oil,  should  be  given 
after  meals — a  teaspoonful  of  the  sirup,  of  either  phosphate  or  phos- 
phite, but  preferably  of  lactophosphate  of  lime,  and  a  teaspoonful  of 
cod-liver  oil.  They  may  be  given  in  an  emulsion  simultaneously,  or 
one  may  follow  the  other,  and  they  should  be  taken  without  failure 


ANEURISM   OF   THE   AORTA.  291 

for  months  at  a  time.  Quinia  should  be  given  in  five-grain  doses, 
morning  and  evening,  on  alternate  days  at  various  times.  Personal 
habits  contributing  to  arterial  degeneration  should  be  discontinued. 
A  syphilitic  taint  should  be  corrected,  and  lead  or  other  poison  depos- 
ited in  the  tissues  should  be  eliminated.  The  diet  should  be  composed 
of  nutritious  materials,  but  indigestion  ought  to  be  avoided.  Daily  out- 
door air  and  moderate  exercise  are  very  necessary  hygienic  measures. 


ANEURISM    OP    THE    AORTA. 

Definition. — An  aneurism  is  a  tumor  formed  of  the  coats  of  an 
artery,  and  containing  blood  and  fibrin.  They  are  designated  cylin- 
drical, fusiform,  or  sacciform,  according  to  their  shape  ;  and  true  if  all 
the  layers  are  engaged,  false  if  one  or  two  form  the  walls  of  the  sac. 
A  dissecting  aneurism  is  one  in  which,  the  intima  and  media  giving 
way,  the  blood  dissects  along  underneath  the  adventitia,  and  the  walls 
of  the  sac  are  composed  of  this  membrane  only.  A  varicose  ajieurism 
is  one  in  which  a  communication  is  established  with  the  venae  cavae, 
the  innominatse,  the  right  auricle,  or  the  pulmonary  artery.  The  ana- 
tomical distinctions  on  which  these  names  are  based  are  important 
chiefly  from  the  prognostic  point  of  view. 

Causes. — The  aorta  is  the  favorite  site  of  aneurisms,  because,  in  the 
performance  of  its  functions,  it  is  subjected  to  great  strain.  If  the 
left  ventricle  is  hypertrophied,  the  blood  -  pressure  in  the  aorta  is 
increased,  and  the  tendency  to  the  formation  of  aneurism  is  greater. 
Powerful  muscular  effort  has  the  same  effect,  and  hence  those  who 
are  engaged  in  occupations  requiring  the  exertion  of  their  utmost 
strength  suffer  more  from  this  malady  than  those  having  easier  pur- 
suits. Men  are  more  liable  to  the  disease  than  women,  and  for  the 
same  reason  that  those  who  labor  hard  suffer  more.  The  frequent 
association  of  syphilitic  infection  and  aneurism  has  attracted  much 
attention,  but  a  causal  relation  has  not  yet  been  established.  Chronic 
arteritis  is,  doubtless,  the  chief  cause  ;  the  tunics  of  the  vessel,  weak- 
ened by  the  structural  alterations,  yield  more  and  more  under  the 
force  of  the  blood  -  pressure.  To  this  view,  which  is  generally  ac- 
cepted, is  opposed  the  important  fact  that,  while  aneurism  is  most 
usual  between  thirty  and  forty,  atheroma  rarely  sets  in  until  after 
forty.  On  the  other  hand,  it  may  be  alleged  that  aneurism  would  be 
vastly  more  frequent  if  the  changes  in  the  structure  of  arteries  oc- 
curred earlier  in  life  ;  and,  furthermore,  in  cases  of  aneurism,  the 
existence  of  atheromatous  degeneration  can  almost  always  be  ascer- 
tained. 

Pathological  Anatomy. — In  Sibson's*  collection  of  cases  of  aneu- 

*  Sibson's  "  Medical  Anatomy,"  London,  1S69  (sec  columns  57-60). 


292  DISEASES   OF   THE   BLOOD-VESSELS. 

rism  occupying  some  part  of  the  aorta,  880  in  number,  703  were  of 
the  thoracic  aorta,  the  others  of  the  abdominal  and  its  branches.  Of 
these,  193  were  of  the  ascending  aorta,  87  occurring  at  the  sinuses 
of  Valsalva.  This  statistical  fact  is  a  confirmation  of  the  pathologi- 
cal law  that  those  parts  most  subject  to  strain  in  the  ordinary  course 
of  functional  work  soonest  become  diseased.  Next  to  the  ascending 
part,  comes  the  arch  which  was  the  seat  of  aneurism  in  120,  while 
only  72  were  in  the  descending  aorta.  As  regards  the  form  assumed 
by  the  aneurism,  two  thirds  of  those  affecting  the  ascending  part  are 
examples  of  the  sacculated  variety.  It  is  a  curious  fact  that,  while 
aneurisms  of  either  the  ascending  or  transverse  aorta  are  sacculated, 
those  involving  both  parts  of  the  vessel  are  cylindrical  or  fusiform 
(Sibson).  In  the  descending  aorta,  the  sacculated  are  about  two 
thirds  of  the  whole  number.  The  direction  taken  by  the  aneurism 
of  the  ascending  aorta  is  usually  to  the  right  of  the  transverse  part, 
about  one  half  toward  the  back,  the  other  half  to  the  right  and  front ; 
of  the  descending,  to  the  left  and  posteriorly. 

The  sac  of  the  aneurism,  which  in  the  beginning  is  composed  of 
the  tunics  of  the  vessel,  or  of  the  adventitia,  is  subjected  to  various 
pathological  influences  which  alter  its  character.  It  is  affected  by 
atheroma,  by  calcification,  but  is  still  more  changed  in  structure  by 
attacks  of  inflammation  which  unite  it  to  neighboring  organs.  The 
author  has  met  with  a  case  in  which  the  proper  sac  had  disappeared, 
and  the  walls  were  made  up  for  the  most  part  of  the  tissue  of  the  left 
lung  in  which  it  was  imbedded.  The  interior  of  the  sac  is  altered  by 
successive  deposits  of  fibrin,  differing  in  age,  color,  and  density,  and 
having  a  distinctly  stratified  arrangement.  The  oldest  layers  are 
grayish-white,  tough,  and  firmly  adherent  to  the  inner  surface  of  the 
sac,  while  the  recent  coagula  contain  more  or  less  coloring  matter, 
are  softer,  easily  broken  up  and  detached.  By  the  gradual  addition 
of  layers  of  fibrin  the  sac  is  ultimately  closed,  and  a  cure  is  effected 
by  the  obliteration  of  the  cavity.  Sometimes  the  outermost  layers  of 
fibrin  undergo  calcification  ;  sometimes  an  acute  inflammation  is  set  up 
and  the  sac  is  destroyed  by  suppuration.  Occasionally  blood-clots  or 
masses  of  fibrin  are  cast  off,  with  the  effect  to  block  the  efferent  vessel, 
or  some  of  its  tributaries,  or,  breaking  up,  are  distributed  as  multiple 
emboli.  The  mischief  caused  by  an  aneurism  is  not  limited  to  the  sac 
itself,  but  involves  neighboring  organs  by  pressure,  interfering  with 
functions,  or  inducing  inflammation,  ulceration,  and  atrophy.  The 
bronchi,  oesophagus,  or  thoracic  duct,  may  be  opened  by  ulcei-ation,  or 
the  vena  cava  occluded  by  a  thrombus,  or  invaded  by  ulceration,  thus 
producing  an  aneurismal  varix,  or  atrophy  of  the  neighboring  lung 
may  be  caused  by  pressure.  The  ribs,  sternum,  and  vertebrae  may  be 
eroded,  and  the  spinal  cord  compressed.  Important  nerve-trunks  are 
first  irritated  by  the  proximity  of  the  tumor,  next  inflamed  by  pres- 


ANEURISM   OF   THE  AORTA.  293 

sure,  and  ultimately  so  mixed  in  the  elements  of  the  sac  as  to  disap- 
pear. If  the  aneurism  occur  in  the  sinuses  of  Valsalva,  the  aortic 
valves  become  incompetent  by  reason  of  changes  in  the  orifice.  It 
had  been  generally  maintained  that  aneurism  of  the  aorta  causes 
hypertrophy  of  the  heart,  but  Sir  Dominic  Corrigan,  Professor  Axel 
Key,*  of  Stockholm,  and  others,  have  shown  that  "  aneurism  has  no 
tendency  to  jDroduce  enlargement  of  the  heart  "  (Corrigan)  ;  and,  when 
hypertrophy  coexists  with  aneurism,  there  is  no  causal  connection. 

Tei-mination  by  rupture  is  the  most  common.  As  regards  aneu- 
risms of  the  sinuses  of  Valsalva,  about  eighty  per  cent,  terminated  by 
rupture  ;  of  the  ascending  aorta,  fifty-seven  per  cent,  ended  by  rup- 
ture ;  of  the  transverse,  thirty-seven  per  cent.  ;  of  the  descending 
aorta,  seventy-five  per  cent.  (Sibson).  Rupture  of  the  ascending  aorta 
occurs  into  the  pericardium  (in  one  half  of  the  cases),  into  the  right 
auricle,  into  the  lung,  into  the  pleura,  into  the  right  bronchus,  into  the 
trachea,  into  the  oesophagus,  or  externally  ;  of  the  transverse  portion, 
into  the  trachea,  lungs,  cesophagus,  pleura,  posterior  mediastinum,  pul- 
monary artery,  or  vena  cava  ;  of  the  descending  portion,  into  the 
pleura,  lungs,  etc. 

Symptoms. — The  signs  and  symptoms  of  aneurism,  as  of  cardiac 
diseases,  are  comprehended  in  two  groups  :  rational  and  physical. 
The  rational  signs  are  symptomatic  of  the  functional  troubles  caused 
by  the  aneurism,  and,  of  course,  vary  somewhat  with  the  position  of 
the  new  formation.  It  will  conduce  to  clearness  to  consider  the  sub- 
ject of  aneurism  of  the  thoracic  aorta  and  its  main  branches  first,  and 
follow  with  aneurism  of  the  abdominal  aorta  and  its  main  branches. 

Aneurism  of  the  Thoracic  Aorta. — The  earliest  symptom  is  pain. 
This  may  be  a  fixed  pain,  almost  constant,  and  felt  in  one  spot  under 
the  sternum  and  in  the  neighborhood  of  the  aneurism.  More  fre- 
quently the  pain  has  a  combined  lancinating  and  tensive  character, 
shooting  up  from  the  interior  of  the  chest  to  the  neck,  to  the  shoulder, 
down  the  arm  to  the  elbow,  sometimes  to  both  sides  ;  or,  it  is  felt  in 
the  back  and  shoots  around  the  chest  in  the  direction  of  the  intercos- 
tal nerves.  At  times  the  attacks  of  pain  are  most  severe,  and  demand 
the  use  of  active  anodynes.  These  pains,  which  occupy  the  trajectory 
of  the  cervical  and  brachial  plexus,  and  of  the  intercostal  nerves,  ought 
not  to  be  confounded  with  attacks  simulating  closely  angina  pectoris, 
which  occur  when  the  aneurism  is  near  the  heart.  These  paroxysms 
consist  of  praecordial  pain  and  anxiety— pain  shooting  across  the  chest, 
in  the  precordial  region,  and  to  the  shoulder,  down  the  arm.  Although 
these  attacks  are  due  to  the  irritation  of  the  nerve-trunks,  they  affect 
a  different  set  of  nerves,  those  supplying  the  heart  itself.  So  constant 
is  this  symptom  of  pain,  so  severe  and  persistent,  although  paroxys- 

*  The  "Medical  Times  and  Gazette,"  June  4,  ISTO. 


294  DISEASES   OF   THE   BLOOD-VESSELS. 

mal,  that,  if  it  come  on  in  a  man  of  middle  age  without  any  explanation, 
aneurism  should  be  suspected  in  the  absence  of  more  characteristic  symp- 
toms. There  is  also  more  or  less  dyspnoea,  paroxysmal  rather,  in  the 
initial  period,  a^xl  may  occur  without  any  apparent  cause,  from  pres- 
sure on  the  pneumogastric  when  there  is  apt  to  be  nausea  associated 
with  it,  or  to  pressure  on  the  phrenic,  when  there  may  be  hiccough. 
In  the  further  development  of  the  aneurism,  dyspnoea  may  be  pro- 
duced by  pressure  on  the  left  primary  bronchus,  diminishing  the  air 
passing  to  the  left  lung  or  on  the  trachea,  or  to  pressure  interfering 
with  the  return  of  blood  from  the  lung,  and  there  may  be  simultane- 
ously pressure  on  the  pneumogastric,  causing  laryngeal  symptoms,  and 
on  the  phrenic,  causing  paralysis  of  the  diaphragm.  When  the  dysp- 
noea is  due  to  pressure  on  the  recurrent  laryngeal,  there  will  be  asso- 
ciated with  it  peculiarities  of  the  voice,  cough,  and  breathing.  When 
due  to  pressure  on  the  trachea,  it  is  somewhat  relieved  by  inclining  the 
head  forward  ;  and  in  one  case,  that  of  a  physician  seen  by  the  author, 
a  violent  suffocative  attack  was  brought  on  by  raising  the  head  erect. 
In  other  cases  of  pressure  on  either  bronchus,  relief  to  the  breathing 
is  afforded  by  turning  to  the  opposite  side.  When  the  dyspnoea  is 
due  to  direct  pressure  on  the  lung,  there  are  present  fever,  profuse 
expectoration,  etc.,  the  signs  of  phthisis.  When  the  aneurism  is  at  the 
arch  and  springs  from  the  inferior  segment,  pressure  on  the  recurrent 
laryngeal  will  produce  characteristic  symptoms  at  an  early  period.  If 
the  pressure  irritates  without  destroying  the  nerve,  all  of  the  muscles 
of  the  larynx  innervated  by  it  will  be  thrown  into  a  state  of  spasm, 
with  the  effect  to  modify  the  voice  and  cough  in  a  most  characteristic 
manner.  While  one  cord  approximates  its  fellow  and  vibrates  in  the 
normal  manner,  the  other  is  in  a  state  of  rigidity  and  does  not  vibrate 
normally,  producing  an  odd  effect  on  the  voice,  there  being  a  double 
tone,  one  high-pitched  and  the  other  lower ;  but  this  vox  anserina 
occurs  with  both  inspiration  and  expiration.  Alteration  of  the  voice 
is  much  more  common  than  aphonia.  When  the  paralysis  of  the  vocal 
cords  is  double,  which  is  an  extremely  rare  event,  the  voice  is  gone 
and  there  is  aphonia  ;  but,  if,  as  is  usually  the  case,  the  paralysis  is  of 
the  left  vocal  cord,  the  voice  has  a  harsh,  stridulous  character.  The 
cough  exhibits  the  same  peculiarities.  When  the  nerve  is  irritated 
without  being  destroyed,  the  cough  is  loud,  resonant,  and  metallic — 
croup-like  ;  on  the  other  hand,  when  the  nerve  is  destroyed  and  the 
muscles  of  the  larynx  paralyzed,  the  cough  is  suppressed,  wheezy,  strid- 
ulous. By  laryngoscopic  examination,  the  explanation  of  these  phe- 
nomena is  afforded  in  the  character  of  the  movements  of  the  arytenoid 
cartilages  and  vocal  cords.  The  effect  of  ii-ritation  is  seen  in  the  rigid 
state  of  one  cord,  which  does  not  approximate  accurately  its  fellow 
during  phonation,  and  vibrates  imperfectly  if  at  all.  When  the  de- 
struction of  the  nerve  is  effected  and  paralysis  comes  on,  the  paralyzed 


ANEURISM   OF  THE   AORTA.  295 

vocal  cord  is  relaxed,  wrinkled,  and  does  not  move  up  to  its  fellow 
during  phonation,  nor  does  the  inspiratory  dilatation  take  place  on  the 
paralyzed  side.  Irritation  of  the  main  trunk  of  the  pneumogastric 
may,  as  has  been  pointed  out,  cause  respiratory  disturbances,  par- 
oxysms having  an  asthmatic  character,  etc.,  but  the  peculiarities  of 
voice  and  speech  above  mentioned  are  only  produced  by  lesions  of  the 
recurrent  laryngeals,  and  chiefly  of  the  left  nerve.  Several  cases  of 
bilateral  paralysis  of  the  larynx  have  resulted  from  the  pressure  on  the 
nerve  of  one  side  only.  Dr.  George  Johnson  *  supposes  this  to  be  due 
to  a  reflex  influence  transmitted  by  the  commissural  connection  be- 
tween the  nuclei  of  the  spinal  accessory,  and  this  is  most  probably  the 
true  explanation,  although  it  has  been  opposed. 

The  state  of  the  pupil  has  a  high  degree  of  clinical  importance. 
If  the  aneurism  irritate  the  fibers  of  the  sympathetic  nerve  without 
destroying  them,  this  fact  is  signalized  by  permanent  dilatation  of  the 
pupil ;  but  if  the  nerve-fibers  are  destroyed,  paralysis  of  the  radiating 
fibers  of  the  iris  ensues,  and  hence  contraction  of  the  pupil  follows 
(the  thii'd  pair  unopposed).  Usually  spasm  of  the  glottis  (irritation 
of  the  inferior  laryngeal)  coincides  with  dilatation  of  the  pupil  (irri- 
tation of  the  sympathetic)  ;  but  this  relation  is  not  invariable,  for 
spasm  of  the  glottis  may  be  present  with  contracted  pupil  (Russell). 
Unilateral  sweating  of  the  head  and  face  is  a  symptom  which  occurs 
in  a  small  proportion  of  cases,  and  may  or  may  not  be  coincident  with 
changes  in  the  pupil.  The  sweating  is  strictly  limited  to  one  side  of 
the  head  and  face,  and,  although  increased  by  external  warmth  and 
exercise,  comes  on  quite  independently  of  external  conditions.  It  is 
supposed  to  indicate  irritation  of  the  sympathetic,  but  the  real  nature 
of  the  phenomenon  is  as  yet  unknown.  As  unilateral  sweating  is  pro- 
duced by  a  variety  of  causes,  it  is  of  importance  in  this  connection 
only  when  it  coincides  with  other  and  more  definite  signs. 

The  character  of  the  cough  associated  with  laryngeal  troubles  has 
been  mentioned.  There  is  also  cough  when  the  lungs  are  involved,  and 
sometimes  profuse  expectoration.  Cough  is  a  symptom  of  pressure  on 
the  trachea  or  bronchi.  Expectoration  of  blood  from  a  minute  com- 
munication between  the  sac  of  the  aneurism  and  trachea  is  one  of  the 
puzzling  symptoms,  for  it  may  have  all  the  characteristics  of  an  ordi- 
nary pulmonary  haemorrhage.  This  escape  of  blood  may  continue  for 
several  weeks  by  a  circuitous  channel,  before  rupture  finally  occurs. 
Dysphagia  or  difficulty  of  swallowing  is  produced  by  the  same  mechan- 
ism as  the  laryngeal  spasms  :  irritation  of  the  pneumogastric  is  reflected 
over  the  motor  branches  distributed  to  the  oesophagus.  This  does  not 
continue  a  permanent  disability,  but  persists  for  a  few  hours,  then  dis- 
appears, to  return  again  at  some  uncertain  period.     Pressure  of  the 

*  "The  British  Medical  Journal,"  December  19,  1874. 


296  DISEASES   OF   THE   BLOOD-TESSELS. 

aneurism  on  the  oesopliagus  produces  a  more  permanent  dysphagia,  and, 
as  might  be  expected,  is  a  more  common  symjitom  in  aneurism  of  the 
descending  aorta  than  in  any  other  position.  According  to  the  statis- 
tics of  Sibson,  dysphagia  was  present  in  thii-ty-five  per  cent,  of  cases  of 
the  descending  aorta,  in  thirty-one  per  cent,  of  those  of  the  arch,  and  in 
only  two  per  cent,  of  those  of  the  ascending  aorta.  As  the  aneurism 
enlarges,  important  symptoms  are  produced  by  pressure  on  the  great 
vessels.  If  the  descending  cava  is  obstructed,  bilateral  cedema  of  the 
face  and  arms  follows,  or,  if  the  innominata  only  is  compressed,  the 
effusion  is  limited  to  the  right  side  or  to  the  left  side,  according  as  it 
is  the  right  or  left  vein.  When  the  right  auricle  is  im^^inged  on,  there 
must  ensue  cyanosis,  general  venous  stasis,  and  dropsy  ;  when  the  left 
auricle,  pulmonary  congestion  with  its  consequences — brown-red  indu- 
rations, haBmorrhagic  infarctions,  etc.  Dilatation  of  the  lymphatic  ves- 
sels will  be  produced  by  the  pressure  of  an  aneurism  occupying  the 
last  portion  of  the  arch  and  the  descending  aorta. 

When  an  aneurismal  tumor  protrudes  at  the  thoracic  wall,  the  diag- 
nosis by  the  physical  method  becomes  much  simplified.  By  palpa- 
tion, the  existence  of  a  tumor,  pulsating  and  swelling  with  each  pulsa- 
tion, is  made  out.  The  first  beat  is  stronger  and  more  prolonged  than 
the  second,  if  there  are  two,  and  is  a  little  subsequent  to  the  heart- 
beat, while  it  anticipates  the  radial  pulse.  The  second  corresponds 
to  the  diastole  of  the  heart,  and  is  the  recoil  from  the  closure  of  the 
aortic  valves,  and  of  course  is  indistinct  or  wanting  when  the  aortic 
valves  are  incompetent.  A  double  pulsation  exists  only  in  the  case 
of  recent  aneurism,  and  of  the  thoracic  aorta  ;  old  aneurisms,  lined 
with  thick  layers  of  fibrin,  or  comjjosed  of  bony  tissue,  can  not  be 
thrown  into  vibration  by  the  comparatively  feeble  force  of  the  recoil 
wave,  and  abdominal  aneurisms  lie  at  too  great  a  distance.  Palpa- 
tion also  reveals  a  peculiar  thrill  or  tremor  which  is  intermittent,  or 
is  synchronous  with  the  first  beat,  and  is  known  as  aneurismal  thrill. 
It  is  obvious  that,  to  feel  this,  a  tumor  must  be  very  superficial,  and 
without  dense,  thick,  or  bony  walls.  In  the  case  of  aneurisms  deeply 
placed  in  the  thoracic  caAdty,  these  symptoms  ascertainable  by  palpa- 
tion are  wanting.  Dullness  on  percussion  is  elicited  only  when  the 
aneurism  has  attained  sufficient  size  or  is  in  a  position  to  cause  the  reac- 
tion, and  it  exists  over  a  very  limited  area  under  any  circumstances.  The 
usual  jjosition  of  the  dullness  is  on  the  right  of  the  sternum,  parallel 
with  the  second  or  third  rib  ;  or  it  is  at  the  sternum,  or  to  the  left  of 
the  sternum,  and  posteriorly  to  the  left  of  the  spinal  column.  This 
symptom  does  not  afford  precise  indications,  since  the  dullness  of  an- 
eurism does  not  differ  from  that  caused  by  any  tumor,  or  by  a  solid 
organ,  or  by  a  purulent  depot.  On  auscultation  we  hear  in  aneurism 
a  systolic  and  diastolic  sound  or  shock,  such  as  is  audible  over  the  ar- 
tery itself.     These  sounds  correspond  to  the  pulsations,  with  the  excep- 


ANEURISM  OF  THE  AORTA.  297 

tion,  however,  that  a  diastolic  sound  may  occur  when  there  is  a  systolic 
and  not  a  diastolic  pulsation.  The  mechanism  of  their  production  is 
obvious  enough,  the  systolic  sound  being  due  to  the  vibration  of  the 
column  of  blood  propelled  into  the  sac,  and  the  diastolic  to  the  recoil 
from  the  shutting  of  the  aortic  valves.  The  second  or  diastolic  sound 
has  a  "  booming "  quality,  and  is  heard  the  more  perfectly  the  nearer 
the  heart  the  aneurism  is  jilaced.  When  there  are  cardiac  murmurs  of 
stenosis  or  insufficiency,  or  peculiarities  of  accentuation,  they  are  prop- 
agated to  and  are  audible  over  the  aneurism.  The  fitness  of  the  expres- 
sion, that  when  aneurism  is  present  "two  hearts  are  beating  in  the 
chest,"  is  quite  obvious  ;  so  close,  indeed,  is  the  resemblance  that  the 
sounds  heard  in  aneurism  were  considered  by  Laennec  as  cardiac  en- 
tirely. Murmurs  also  occur  in  aneurism  with,  or  take  the  place  of, 
the  sounds  ;  they  are  formed  in  or  of  the  sac,  and  are  not  propagated 
from  the  heart.  They  are  by  no  means  common,  and  a  diastolic  mur- 
mur is  greatly  less  frequent  than  a  systolic.  They  are  produced  by 
some  irregularity  in  the  interior  of  the  sac,  or  by  pressure  on  a  neigh- 
boring vessel,  or  on  an  adjacent  part  of  the  aorta.  A  sacculated  an- 
eurism does  not,  but  the  other  varieties  do  in  some  cases,  retard  the 
pulse-beat.  If  it  occupy  the  ascending  aorta  the  pulse  will  be  behind 
on  the  whole  round  of  the  circulation  ;  if  the  transverse  portion  of  the 
arch  and  between  the  arteria  innominata  and  the  left  subclavian,  the 
pulse  of  the  radial  will  be  retarded  ;  if  the  descending  aorta,  the  fem- 
oral pulse  will  be  delayed.  The  pulse  is  also  changed  in  character. 
If  the  orifice  of  the  efferent  vessel  is  unobstructed,  the  normal  dicro- 
tism  of  the  pulse  is  increased  because  of  the  secondary  undulation  im- 
parted to  the  blood-column  ;  on  the  other  hand,  if  the  efferent  vessel 
is  narrow  or  obstructed,  the  pulse  is  small,  irregular,  and  without 
dicrotism. 

The  symptoms  of  aortic  aneurism  vary  with  the  position  of  the  sac 
in  the  course  of  the  vessel.  In  aneurism  of  the  ascending  part  there 
are  pressure  on  the  right  auricle,  cyanosis,  venous  stasis,  and  dropsy. 
The  aortic  valves  are  usually  incompetent,  and  the  murmurs  thus  pro- 
duced are  audible  over  the  sac.  As  the  tumor  develops  anteriorly,  the 
pulsation  is  felt  in  the  second  or  third  right  intercostal  space  at  the 
border  of  the  sternum.  When  it  projects  it  forms  an  hemispherical 
tumor,  having,  usually,  a  double  pulsation,  a  reddish  and  purplish  tint, 
is  crossed  by  enlarged  and  varicose  veins,  and  presently  softens.  The 
radial  pulse  is  retarded  equally  on  both  sides,  unless  compression  of  the 
innominate  artery  occurs.  The  laryngeal  symptoms,  so  constant  in 
aneurism  of  the  arch,  are  wanting,  but  the  pupillary  phenomena  and  the 
unilateral  sweating  may  be  present.  The  trachea  and  oesophagus  are 
occasionally  encroached  upon,  but  the  right  primary  bronchus  may  be 
compressed.  In  about  one  half  of  the  cases  the  pulmonary  artery  and 
the  adjacent  right  ventricle  are  impinged  on.     According  to  the  data 


298  DISEASES   OF   THE   BLOOD-VESSELS. 

of  Sibson,  aneurisms  of  the  ascending  aorta  compressed  the  right  lung 
in  thirty-four  instances,  the  left  lung  in  ten,  the  right  bronchus  in  six, 
the  left  bronchus  in  one,  the  pulmonary  artery  in  seven,  the  descending 
vena  cava  in  sixteen,  and  the  trachea  and  oesophagus  in  nine  each.  In 
aneurism  of  the  arch  there  will  be  oedema  of  the  head  and  upper  ex- 
tremities ;  the  pupil  will  be  affected  but  not  invariably  ;  laryngeal 
symptoms  will  be  usually  present  from  compression  of  the  left  recurrent 
nerve  ;  there  will  be  compression  of  the  left  primary  bronchus,  and 
consequent  feeble  respiration  or  collapse  of  the  left  lung  ;  there  will 
be  dysphagia  from  obstruction  of  the  oesophagus  sometimes  ;  attacks 
of  angina  pectoris  from  irritation  of  cardiac  nerves.  Referring  again 
to  the  facts  of  Sibson,  we  find  in  regard  to  aneurism  involving  both  the 
ascending  and  transverse  aorta,  that  there  were  present  dyspnoea  in 
74  per  cent.,  orthopnoea  in  21-5,  cough  in  47,  haemoptysis  in  10,  stridu- 
lous  breathing  or  affection  of  voice  in  17,  dysphagia  in  21*5,  the  head 
and  neck  were  swollen  in  14  per  cent.  ;  while  in  aneurism  of  the  trans- 
verse aorta  alone  there  were  present,  dyspnoea  in  71  per  cent.,  orthop- 
noea in  20  per  cent.,  cough  in  57*5  per  cent.,  hsemoptysis  in  19  per  cent., 
inspiration  stridulous  in  47*5  per  cent.,  dysphagia  in  31  per  cent.,  the 
pulse  weaker  in  one  wrist  in  26  per  cent.  As  regards  the  descending 
part  of  the  arch  of  the  aorta,  we  find  that  the  vertebrae  were  eroded 
in  42  per  cent.  ;  the  tumor  made  pressure  on  the  trachea  in  12*5  per 
cent.,  on  the  left  primary  bronchus  in  37'5  per  cent.,  on  the  oesophagus 
in  31  per  cent.,  the  left  lung  in  48  per  cent,  ;  dysi^noea  occurred  in  50 
per  cent.,  cough  in  46  per  cent.,  the  voice  affected  in  25  per  cent.,  and 
dysphagia  existed  in  33  per  cent.  The  important  disturbances  arising 
from  aneurism  in  this  situation  are  obviously  due  to  the  recurrent 
laryngeal  nerve,  left  primary  bronchus,  oesophagus,  and  trachea,  which 
come  into  close  relation  with  the  vessel  at  this  point.  Aneurisms  lower 
down  compress  the  left  lung,  and  cause  erosion  of  the  vertebrae  in  74 
per  cent.  There  is  a  fixed  boring  pain  about  the  site  of  the  aneurism 
in  one  half  the  cases  ;  there  is  also  much  pain  in  the  intercostal  nerves  ; 
the  femoral  pulse  is  retarded  ;  and,  when  the  spinal  canal  is  invaded, 
disorders  of  sensation  and  of  motility  occur  in  the  lower  limbs,  termi- 
nating in  hemiplegia.  A  case  is  reported  of  an  aneurism  of  the  arch, 
dissecting  downward  between  the  trachea  and  oesophagus  and  bursting 
into  the  stomach.  The  symptoms  were  orthopnoea,  dysphagia,  and 
stricture  of  the  oesophagus,  but  not  of  aneurism.* 

Aneurism  of  the  innominata  causes  very  much  the  same  symptoms 
as  the  first  part  of  the  arch  :  a  systolic  and  a  diastolic  pulsation  ;  a 
double  sound,  synchronous  with  the  cardiac,  and  audible  with  the 
greatest  intensity  at  the  junction  of  the  clavicle  and  sternum  ;  retar- 
dation and  increased  dicrotism  of  the  right  radial  pulse  if  undbstiaicted 

*  "Pathological  Society's  Transactions,"  vol.  xxvii,  p.  9Y,  report  of  Dr.  Frederick  Taylor, 


ANEURISM   OF   THE   AORTA.  299 

at  orifice  of  exit  ;  pain  in  the  neck  and  arm  ;  compression  of  the  de- 
scending vena  cava,  and  oedema  of  the  head  and  upper  extremities,  or 
there  may  be  compression  of  the  left  vena  innominata,  and  consequent 
oedema  of  the  left  side  of  the  head  and  the  left  arm. 

Aneurism  of  the  Abdotnmal  Aorta. — The  point  of  election  is  at  or 
near  the  coeliac  axis.  In  Dr.  Sibson's  collection  of  cases,  177  in  num- 
ber, 131  occurred  at  this  point.  Less  than  one  half  arise  from  the  an- 
terior face  of  the  vessel,  and  consequently  the  vertebrae  are  eroded  in 
a  large  proportion  of  cases — 55  per  cent.  The  variety  of  the  aneurism 
is  the  so-called  false,  and  the  form  sacculated  in  60  per  cent.,  and  they 
attain  considerable  size,  sometimes  to  a  capacity  of  ten  pounds. 

Aneurism  of  the  abdominal  aorta  is  usually  referred  to  a  violent 
muscular  effort — always,  in  the  author's  experience.  It  appears  to  be 
less  associated  with  atheromatous  degeneration  of  the  arteries  than  is 
aneurism  of  the  thoracic  aorta.  One  of  the  earliest  symptoms  is  pain, 
felt  in  the  position  of  the  tumor  and  radiating  through  the  abdomen. 
As  the  aneurism  is  so  situated  that  the  semilunar  ganglion  and  the 
nerves  of  the  solar  plexus  must  be  compressed  by  it,  pain  is  necessarily 
produced,  and,  as  the  nerves  radiate  from  a  common  center,  the  pain 
also  radiates,  shooting  up  into  the  hypochondria  and  downward  to  the 
iliac  regions  and  hypogastrium.  These  pains  are  paroxysmal,  and  may 
disappear  for  hours  and  days  ;  but  the  attacks  are  of  extreme  severity, 
and  when  they  subside  leave  the  patient  exhausted.  The  local  pain 
seems  to  the  patient  to  be  in  the  stomach,  and,  as  this  organ  is  disturbed 
in  function  also,  the  attacks  are  often  confounded  with  gastralgia.  This 
local  pain  is  more  constant  than  the  other,  and  there  is  rarely  an  entire 
cessation  of  it,  although  it  may  be  little  more  at  times  than  an  uneasi- 
ness. In  about  one  half  of  the  cases  the  most  violent  pains  occur  in 
the  back,  and  shoot  down  through  the  lumbar  region  into  the  hips 
along  the  course  of  the  sciatic  nerves.  There  is  here  also  a  fixed^ 
boring  pain  felt  opposite  the  coeliac  axis,  which  is  rarely  absent.  In 
both  situations  the  pains  are  aggravated  by  pressure,  by  sudden  jolt- 
ing, or  bending  the  body.  The  pain  in  front  is  increased  by  taking 
food,  especially  by  distention  of  the  stomach.  Distress  produced  by 
eating,  indigestion,  flatulence,  and  nausea,  are  early  symptoms,  due  to 
irritation  of  the  solar  plexus.  As  the  pain  is  brought  on  by  eating, 
and  as  pronounced  stomach  troubles  are  present  in  a  majority  of  the 
cases,  it  need  occasion  no  surprise  that  they  are  often  supposed  to  be 
entirely  stomachal.  This  mistake  is  persisted  in  even  when  a  tumor  is 
present,  and  the  phenomena  are  then  ascribed  to  cancer  of  the  stomach. 
This  mistake  is  all  the  more  readily  made,  since  the  interference  with 
digestion  brings  on  a  cachectic  state  with  wasting,  and  since  jaundice 
may  be  caused  by  pressure  on  the  common  duct.  The  stomachal  dis- 
orders are  less  pronounced  in  those  aneurisms  springing  from  the  pos- 
terior part  of  the  aorta  and  making  their  way  posteriorly.     According 


300  DISEASES   OF   THE   BLOOD-VESSELS. 

to  Sibson,  a  pulsating  tumor  was  observed  in  55  per  cent,  of  the  cases. 
A  large  tumor  may  form  posteriorly,  and  produce  extensive  erosions 
of  the  vertebrae,  without  being  ascertained  by  the  most  careful  palpa- 
tion. A  dislocated  kidney,  a  migrating  spleen,  a  bunch  of  enlarged 
lymphatics,  may  rest  on  the  aorta  and  receive  a  pulsation  synchronous 
with  the  cardiac  systole.  In  applying  the  method  of  palpation,  to  de- 
termine the  nature  of  a  pulsating  epigastric  tumor,  the  sources  of  error 
just  mentioned  must  be  eliminated  by  putting  the  patient  in  such  a 
position  that  these  bodies  will  fall  away  from  the  aorta,  when,  of  course, 
the  pulsation  will  cease.  The  aneurismal  tumor  is  situated  usually  in 
the  epigastrium,  a  little  to  the  left  of  the  median  line.  It  is  a  globular, 
elastic  tumor,  pulsating  with  an  expansile  movement  in  all  directions, 
and  on  inspection  there  will  be  seen  a  swell  of  the  whole  abdomen  with 
each  pulsation.  The  pulsation  of  an  abdominal  aneurism  is  single,  a 
little  later  than  the  cardiac  systole,  and  there  is  usually  a  thrill.  If 
pressure  is  made  on  the  aorta  below  the  aneurism,  the  sac  will  be  filled 
with  a  stronger  impulse,  and  retain  its  fullness,  while  the  thrill  ceases 
or  is  less  marked.  Percussion  is  of  little  value.  Dullness  may  be  elicit- 
ed under  favorable  circumstances,  but  this  affords  no  indication  of  the 
nature  of  the  producing  cause.  Murmur  is  present  in  a  considerable 
proportion  of  cases.  It  has  a  blowing  character,  is  rather  soft,  and,  in 
time,  is  a  little  later  than  the  cardiac  systole.  When  the  aneurism 
springs  from  the  anterior  surface  of  the  aorta,  the  murmur  is  audible 
in  front,  and,  when  the  growth  is  posterior,  audible  behind  ;  rarely  is 
it  audible  in  both  situations  in  the  same  case.  Standing  erect  arrests 
the  murmur,  because,  according  to  Corrigan,  of  the  increased  tension 
in  the  sac  pi'oduced  by  the  superincumbent  column  of  blood.  To  this 
statement  and  explanation  must  be  opposed  the  important  fact  that 
the  murmur  was  audible  in  the  erect  and  ceased  in  the  recumbent  pos- 
ture in  an  undoubted  case  of  aneurism.  Aneurism  of  branches  of  the 
aorta  iare  occasionally  encountered.  An  aneurism  of  the  mesenteric 
artery  is  a  movable  tumor  which  may  be  confounded  with  floating 
kidney.*  It  differs  from  the  latter  in  being  globular  and  pulsating. 
Aneurism  of  the  hepatic  artery  may  cause  jaundice,  by  pressure  on 
the  duct,  or  ascites,  by  pressure  on  the  portal  vein.  As  they  are  small 
in  size  and  deeply  placed,  aneurisms  of  the  hepatic  artery  are  rarely, 
if  ever,  recognized  during  the  life  of  the  individuals  affected  by  them. 
Course,  Duration,  and  Termination  of  Aneurisms  of  the  Aorta.— 
The  course  of  aneurism  is  much  influenced  by  the  condition  of  organs 
compressed,  and  the  disturbances  of  function  thus  induced.  They  are 
essentially  chronic,  slow  in  development  usually  until  of  sufficient  size 
to  compress  the  organs  about  them,  when  symptoms  are  caused  which 

*  Dr.  Burney-Yeo  communicates  a  case  to  the  Pathological  Society  ("Transactions,"  vol. 
xxviii,  1877),  in  which  the  first  part  of  the  artery  was  affected  and  not  movable.  It  com- 
pressed both  renal  arteries,  and  caused  death  by  uraemia. 


ANEUEISM   OF   THE   AORTA.  301 

attract  attention  to  them.  Not  all  cases  give  rise  to  symptoms  that 
indicate  the  cause  of  the  disturbances  which  they  produce  ;.only  the 
disturbances  are  recognized  and  treated  as  the  real  malady.  Thus, 
aneurisms  deeply  placed  in  the  thorax  posteriorly,  or  of  the  abdominal 
aorta,  high  upon  between  the  crura  of  the  diaphragm,  or  growing 
toward  the  lumbar  region,  may  produce  no  symptoms  which  can  indi- 
cate the  nature  of  the  disease.  Even  when  a  tumor  of  considerable 
size  exists,  in  the  situation  most  favorable  for  recognition,  grave 
doubts  may  be  entertained  as  to  its  aneurismal  character.  They  may 
terminate  in  a  variety  of  modes  ;  by  exhaustion,  by  pneumonia,  by 
rupture  and  haemorrhage.  Probably  the  most  useful  collection  of  sta- 
tistics showing  the  course  and  terminations  of  aneurism  is  that  of 
Sibson,  and  the  author  prefers,  therefore,  to  illustrate  these  points 
from  it.  As  regards  aneurism  of  the  first  part  of  the  aorta  (sinuses 
of  Valsalva),  we  find  that  80  per  cent,  terminated  by  rupture,  45  per 
cent,  into  the  sac  of  the  pericardium,  13*5  per  cent,  into  the  pulmonary 
artery,  8-5  per  cent,  into  the  right  auricle,  5  per  cent,  into  the  right 
ventricle,  and  5  per  cent,  into  the  left  ventricle.  Aneurism  of  the 
ascending  aorta  "  ruptured  in  57  per  cent. ;  externally  in  8,  into  the 
pericardium  in  22,  into  the  pulmonary  artery  in  4,  into  the  descending 
vena  cava  in  5,  into  the  right  lung  in  5,  into  the  left  pleura  in  4,  "  etc. 
In  a  series  of  25  cases  published  in  the  "New  York  Pathological 
Transactions,"  *  the  termination  was  by  rupture  ;  and  in  almost  all  of 
the  cases  death  occurred  suddenly,  but  few  of  them  having  been  diag- 
nosticated. Aneurisms  of  the  ascending  aorta  and  arch  conjointly  rup- 
tured in  37  per  cent.,  into  the  pericardium  in  10,  into  the  vena  cava 
4,  into  the  trachea  4,  etc.  Aneurism  of  the  descending  part  of  the 
arch  ruptured  in  75  per  cent.,  into  the  trachea  in  4,  into  the  left  bron- 
chus in  16-5,  into  the  left  pleura  in  23,  into  the  right  pleura  in  12-5, 
etc.  Aheurism  of  the  abdominal  aorta  ruptured  in  77  per  cent.,  into 
the  peritoneal  cavity  in  28*5  per  cent.,  into  the  subperitoneal  tissue,  in 
the  left  hypochondriac  region,  22  per  cent.,  etc.  Although  death  is 
almost  immediate  when  an  aneurism  ruptures,  yet  this  is  not  invaria- 
bly the  case.  A  small  opening  may  exist  in  the  trachea,  permitting  a 
little  blood  to  escape  from  time  to  time,  simulating  pulmonary  hsem- 
orrhage,  and  continuing  to  discharge  in  this  way  until  a  complete  rup- 
ture occurred  at  the  end  of  several  months.  These  are  called  "  weep- 
ing aneurisms."  Gairdnerf  records  a  case  of  this  kind  in  which  the 
opening  was  blocked  by  some  fibrin,  and  continued  so  for  four  years. 
An  opening  externally  may  discharge  slowly,  of  which  notable  exam- 
ples have  been  published — a  free  and  fatal  hasmorrhage  being  pre- 
vented usually  by  a  plug  of  fibrin.  As  the  beginning  of  an  aneurism 
is  very  uncertain,  it  is  difficult  to  state  its  duration  within  exact  lim- 

*  Tabulated  in  "  Transactions  of  the  London  Pathological  Society,"  vol.  xxix. 
f  "  Clinical  Medicine,"  op.  cit. 


302  DISEASES   OF  THE   BLOOD-VESSELS. 

its.  They  vary  exceedingly  in  duration  ;  from  fifteen  days  to  thirty 
years  are  the  extremes  which  have  fallen  under  the  author's  notice. 
Much  depends  on  the  influences,  medicinal  and  moral,  to  which  the 
patient  is  subjected.     Some  cures  are  effected. 

Prognosis. — Aneurism  must  be  regarded  as  a  very  grave  disease. 
Under  the  improved  methods  of  medical  treatment  now  available, 
more  cures  are  effected  than  formerly,  and  the  question  of  treatment 
must  enter  largely  into  prognosis.  Under  any  circumstances,  a  quali- 
fied opinion  only  should  be  given,  for  an  aneurism  that  is  apparently 
solidifying  may  take  an  unfavorable  tui*n,  and  death  be  caused  by 
some  intercurrent  malady. 

Treatment. — The  object  of  the  medical  treatment  of  aneurism  is  to 
secure  the  solidification  of  the  sac.  As  this  has  occurred  several  times 
spontaneously,  without  the  intervention  of  art,  it  is  more  difl&cult 
to  assign  to  remedies  their  exact  share  in  any  successful  treatment. 
To  obtain  coagulation  of  the  blood  in  the  sac  and  to  effect  the  solidi- 
fication of  the  fibrin  are  the  objects  before  us.  If  we  have  to  deal 
with  a  sacculated  aneurism,  the  closure  of  the  sac  can  be  accomplished 
without  interrupting  the  current  through  its  proper  channel.  The 
importance  of  this  is  very  obvious  in  dealing  with  the  aorta,  for  no 
collateral  circulation  is  here  possible.  The  difficulty  of  a  case  is  im- 
mensely increased  from  the  therapeutical  standpoint,  when  we  have  to 
treat  a  dilated  vessel.  The  treatment  by  rest,  as  absolute  as  can  be 
maintained,  is  a  very  old  method,  and  has  much  to  recommend  it  even 
now.  If  the  patient  maintains  a  position  of  recumbency,  and  moves 
in  that  position  as  little  as  possible,  the  action  of  the  heart  is  slowed 
and  its  force  lessened,  so  that  the  blood  in  the  sac  may  coagulate. 
Formerly,  the  abstraction  of  blood  and  an  absolute  diet  were  com- 
bined T^-ith  rest  in  the  recumbent  posture  (Valsalva's  plan),  but,  in  the 
more  recent  method  of  Tufnell,  only  the  rest  and  a  restricted  diet  are 
considered  necessary.  The  diet  of  this  plan  consists  of  two  ounces  of 
liquid  and  four  of  solid  food  morning  and  evening,  and  four  ounces 
of  liquid  and  six  ounces  of  solid  at  mid-day.*  In  addition  to  this  re- 
stricted diet,  the  blood-pressure  is  reduced  by  the  daily  use  of  laxa- 
tives. The  period  of  confinement  to  a  recumbent  posture  is  from 
eight  to  thirteen  weeks.  The  results  obtained  by  Mr.  Tufnell  are  cer- 
tainly very  satisfactory,  for  he  has  reported  cases  of  aneurism  of  the 
abdominal  aorta  solidified  in  thirty-seven  and  twenty-one  days,  and 
one  of  popliteal  cured  in  twelve  days  ;  and  he  affirms  that,  "  if  the 
plan  of  treatment  by  position  be  but  steadily  and  perseveringly  car- 
ried out,  a  successful  issue  can  (in  suitable  cases)  almost  be  guaran- 
teed." In  addition  to  rest,  arterial  sedatives  are  sometimes  given,  with 
the  view  to  keep  the  action  of  the  heart  still  lower  than  that  rate  of 

*  "  Mcdico-Chii'urgical  Transactions,"  vol.  xxxix,  1874,  p.  83,  et  seq. 


ANEURISM   OF  THE   AORTA.  303 

movement  attainable  by  rest  merely,  according  to  Tufnell's  plan.  The 
arterial  sedative  employed  for  this  jjurpose  is  the  tincture  of  veratrum 
viride,  given  to  bring  down  and  to  keep  the  pulsations  about  fifty  per 
minute.  The  author  has  witnessed  successes  obtained  in  this  way. 
Bloodletting  is  admissible  in  cases  of  large  aneurism,  a  rupture  being 
threatened  by  violent  action  and  plethora.  Recently,  important  re- 
sults have  been  obtained  by  the  free  administration  of  the  iodide  of 
potassium  (gr.  xv — 3j)  three  times  a  day.  It  has  a  remarkable  influ- 
ence over  the  pain,  probably  because  of  its  effect  in  diminishing  the 
tension  of  the  sac,  the  force  of  the  heart,  and  the  blood-pressure  (Bal- 
four). Besides  this,  the  iodide  seems  to  affect  the  sac  itself.  The  use 
of  the  iodide  of  potassium  may  be  combined  with  rest  and  a  lowei'ed 
diet,  but  these  are  only  adjuvants,  and  are  not  essential  to  the  treat- 
ment. Langenbeck  has  called  attention  to  the  great  value  of  ergotin 
as  a  remedy  in  aneurism,  and  has  reported  some  successful  cases.  It 
has  been  used  since  with  advantage.  Its  employment  is  based  on  the 
action  which  it  exerts  on  the  muscular  fiber  of  the  arteries,  and  there- 
fore, it  is  asserted,  it  can  have  no  effect  on  the  aorta.  Those  who  use 
this  argument  forget  that  ergot  slows  the  heart,  and  raises  the  blood- 
pressure  at  the  periphery  by  contracting  the  arterioles — conditions 
highly  favorable  to  promote  coagulation  of  the  blood  in  the  sac.  Two 
to  five  grains  of  the  so-called  ergotin,  which  is  the  aqueous  extract, 
should  be  administered  hypoderraatically,  simply  dissolved  in  water 
and  filtered.  This  practice  may  be  continued  while  the  other  measures 
are  being  cai'ried  out,  as  there  is  no  therapeutical  incompatibility. 
The  success  which  has  lately  been  obtained  with  barium,  based  on  the 
experimental  research  of  Boehm,  is  a  beautiful  example  of  the  value 
of  such  investigations.  From  3  ss  to  3  j  of  the  liquor  barii  chloridi, 
w^ell  diluted,  may  be  given  three  times  a  day,  after  meals.  The  physi- 
ological effects  of  this  medicine  on  the  vessels  suggested  its  employ- 
m.ent  originally.  Acetate  of  lead  also  affects  the  vessels — especially 
the  intima — but  there  are  very  obvious  objections  to  its  long-contin- 
ued use.  Attempts  have  been  made  by  direct  means  to  secure  the 
coagulation  of  blood  in  the  aneurismal  sac.  These  consist  in  the  in- 
troduction of  fine  wires,  horse-hair,  etc.,  with  the  intent  to  supply  a 
foreign  body  about  which  the  blood  will  coagulate.  Thus  far,  these 
attempts  have  been  failures.  Another  method,  of  which  very  confi- 
dent anticipations  were  at  one  time  entertained,  is  the  method  of  elec- 
trolysis. This  consists  in  the  introduction  of  an  insulated  needle  into 
the  interior  of  a  sac,  and  the  application  of  a  sponge  electrode  to  the 
exterior,  through  which  a  galvanic  current  is  passed.  The  blood  coag- 
ulates about  the  needle.  Much  discussion  has  resulted  as  to  the  pole,, 
anode  or  cathode,  to  be  introduced  into  the  sac.  As  about  the  posi- 
tive pole  acids,  oxygen,  etc.,  collect,  a  firmer  clot  is  there  formed  ; 
while   about   the   negative,  hydrogen  and  the  alkalies,   producing  a 


304  DISEASES   OF  THE   RESPIRATORY   ORGANS. 

softer  clot.  The  positive  electrode  needle  is  withdrawn  with  difficulty 
from  the  sac,  owing  to  the  firmness  and  adhesiveness  of  the  adherent 
coagulum,  and  in  making  the  effort  there  is  danger  of  hsemorrhage 
and  of  setting  free  multiple  emboli.  On  the  other  hand,  although  the 
clot  produced  by  the  negative-  needle  is  less  firm,  it  acts  as  a  nucleus 
about  which  denser  coagula  will  form  afterward.  Although  cures 
have  been  reported  by  electrolysis,  this  method  is  not  so  successful  as 
others  recommended  above.  Furthermore,  the  danger  of  haemorrhage, 
of  exciting  inflammation,  of  detaching  large  clots  in  the  circulation, 
is  so  great  that  this  plan  is  not  to  be  commended. 

Anem'ism  of  the  coronary  artery  is  a  rare  disease.  Crisp  *  has 
collected  and  tabulated  twelve  cases.  They  occurred  from  eleven  to 
seventy-seven  years  of  age,  but  chiefly  after  forty,  and  in  subjects 
exposed  to  such  injury  by  occupation.  They  may  cause  sudden  death 
without  symptoms,  or  there  may  be  suffocative  attacks,  pain,  and  pal- 
pitations. They  vary  in  size  from  a  pea  to  a  walnut,  and  rupture  into 
the  pericardium.  This  is  not  the  invariable  termination,  although 
usual,  death  being  caused  in  three  of  Crisp's  cases  by  bronchitis,  ex- 
haustion, and  an  unknown  cause  unconnected  with  the  aneurism. 


DISEASES   OF  THE  RESPIRATORY  ORGANS. 


INFLAMMATION  OP  THE   PLEURA— PLEURITIS. 

Definition. — JPleuritis,  or  jy^&urisy,  is  an  inflammation  of  the  pleu- 
ral membrane.  Although  not  separable  by  any  well-marked  signs  and 
symptoms,  it  is  usual  to  consider  two  forms,  acute  and  chronic.  It 
may  occur  as  an  independent  ^pr«?2ar?/  affection,  or  it  may  be  secondary 
to  some  other  disease. 

Causes. — There  can  be  little  doubt  that  many  cases  arise  from  ex- 
posure to  cold,  especially  when  a  current  of  cold  air  is  directed  against 
the  body  in  a  perspiring  state.  There  is  probably  a  constitutional 
condition  of  some  kind  which  determines  the  seizure,  but  this  state  can 
not  be  defined.  It  is  more  common  in  early  life  up  to  the  middle 
period,  but  is  uncommon  in  old  age.  The  secondary  disease  is  much 
more  frequently  encountered  than  the  pi'imary.  It  is  very  frequently 
associated  with  pneumonia,  by  extension  of  inflammation  through  con- 
tiguity of  tissue  ;  often,  indeed,  the  pleuritis  is  the  more  important  of 

*  "Transactions  of  the  Pathological  Society,"  vol.  xxii,  p.  108. 


PLEURITIS.  305 

the  two  affections.  It  is  also  associated  with  catarrhal  pneumonia,  with 
bronchitis,  pericarditis,  embolic  pneumonia,  pyaemia,  abscesses,  and 
other  affections  of  the  thoracic  organs.  It  may  be  excited  by  caries 
of  a  rib,  deep-seated  (sub-joleural)  abscesses,  cysts  and  abscesses  of  the 
liver,  etc.  A  dyscrasia  may  be  a  cause,  when  it  is  said  the  pleuritis 
is  an  intercui'rent  malady  ;  but  it  is  now  known  that  various  morbific 
matters  in  the  blood  may  excite  serous  inflammations,  of  which  rheu- 
matism, gout,  Bright's  disease,  cancer,  diabetes,  and  the  eruptive  fe- 
vers may  be  taken  as  examples. 

Pathological  Anatomy. — The  initial  lesion  is  hypersemia  of  the  sub- 
serous connective  tissue,  while  red  points  due  to  congested  vessels  are 
rather  thickly  scattered  over  the  pleura.  Such  is  the  force  of  the  blood- 
pressure  that  minute  points  of  extravasation  occur  on  the  pleura  and 
in  the  subserous  tissue.  The  membrane  has  an  arborescent  or  striated 
appearance,  and  is  of  a  reddish  or  reddish-brown  color.  The  injected 
portion  of  the  membrane  is  dull,  opaque,  and  rough  ;  the  epithelium  is 
swollen,  cloudy,  and  granular,  and  is  rapidly  cast  off,  while  the  ad- 
herent cells  undergo  similar  changes,  and  the  subserous  tissue  becomes 
swollen,  infiltrated,  and  crowded  with  migrated  leucocytes.  On  the 
membrane  there  appears  in  detached  masses,  but  rather  thickly  placed, 
an  exudation  which  makes  the  surface  rough  and  uneven.  Large  flakes 
of  exudation  may  be  thrown  off,  or  the  membrane  may  become  thickly 
covered  with  a  more  or  less  heavy  coating  of  fibrinous  material.  This 
may  also  contain  a  good  deal  of  serous  exudation  in  its  meshes,  when 
it  presents  a  gelatinous,  felt-like,  or  spongy  appearance.  If  there  be 
present  much  liquid,  the  flakes  or  masses  of  fibrin  are  seen  floating  in 
it,  or  they  may  be  churned  up  with  the  serum  and  form  a  milky-look- 
ing fluid.  The  exudation  which  thus  forms  on  the  surface  passes 
through  various  changes.  It  may  undergo  fatty  metamorphosis,  be- 
come emulsionized,  and  disappear  by  absorption,  leaving  the  membrane 
unharmed.  Adhesions  may  form  by  the  gluing  together  of  the  op- 
posed surfaces,  the  connecting  band  of  exudation  undergoing  organi- 
zation. The  membranous  exudation  on  the  surface  may  also  become 
organized;  large  thin-walled  vessels  develop  from  the  leucocytes,  accord- 
ing to  Rindfleisch,  and  close  connections  are  formed  between  the  neo- 
membrane  and  the  pleura.  Again,  broad  patches  of  membranous  exuda- 
tion on  the  opposing  surfaces  of  the  pleura  uniting  by  their  margins,  a 
central  cavity  is  thus  formed  in  which  there  may  be  serum,  sanguino- 
lent  serum,  and  flakes  of  exudation,  etc.,  while  close  adhesions  unite 
the  pleural  surfaces  all  around  for  a  greater  or  less  distance.  These 
secondary  cavities  form  at  the  base,  on  the  lateral  wall  of  the  thorax, 
and  between  the  pleura  and  pericardium,  and,  as  they  retain  the  effu- 
sion in  a  fixed  position,  give  rise  to  errors  of  diagnosis.  Those  are 
examples  of  dry  pleurisy ,  in  which  a  very  plastic  exudation  is  thrown 
out  on  the  two  surfaces,  over  a  small  extent  of  the  membrane,  union 
20 


306  DISEASES  OF  THE  RESPIRATORY  ORGANS, 

taking  place,  either  directly  or  by  a  connecting  band,  there  being  no 
other  exudation  or  effusion.  It  is  probable  that  many  of  the  exam- 
ples of  connecting  bands,  or  adhesions  between  the  pleural  surfaces, 
which  are  found  ^:>os^  mortem,  no  symptoms  having  occurred  during 
life,  were  of  this  character.  Usually,  however,  in  pleuritis,  a  more  or 
less  abundant  exudation  is  poured  out.  According  to  the  nature  of  the 
effusion,  the  cases  of  pleurisy  are  divided  into  the  sero-fibrinous,  the 
purulent,  and  the  hcemorrhagiG. 

In  the  sero-fihrinous  form  there  is  poured  out  from  the  distended 
vessels  a  quantity  of  fluid,  straw-colored  and  having  the  qualitative 
composition  of  blood-serum.  This  contains  floating  in  it  masses  of 
exudation  or  flakes,  leucocytes,  lymph,  and  red-blood  corpuscles,  which 
impart  to  it  a  more  or  less  milky  or  sanguinolent  character.  The 
fibrinous  part  of  the  exudation  consists  of  layers  or  folds  of  whitish, 
grayish,  or  reddish  albuminous  and  fibrinous  material  deposited  on  the 
pleura.  It  may  be  soft,  easily  separated,  or  tough  and  elastic  ;  and 
may  be  readily  detached  from  the  membrane,  or  may  adhere  with 
considerable  tenacity.  When  removed,  this  exudation  is  found  to  be 
closely  adherent  to  a  layer  beneath,  made  up  of  the  proliferating  con- 
nective-tissue corpuscles  of  the  basement  membrane,  together  with 
a  plastic  matrix.  These  layers  become  ultimately  closely  connected 
by  the  growth  of  the  connective-tissue  membrane,  or  the  fibrinous 
exudation  may  undergo  fatty  degeneration  and  be  absorbed.  The 
new  connective-tissue  membrane,  built  up  as  above  described,  is  very 
rich  in  vessels,  and  readily  unites  with  the  same  formation  on  the  op- 
posing surface  of  the  pleura.  The  corpuscular  elements — leucocytes, 
lymph-corpuscles,  cast-off  epithelium,  etc, — in  the  serous  fluid  may  be 
so  abundant  as  to  give  it  a  yellowish  or  purulent  appearance.  Hence 
it  may  be  difiicult  to  make  a  distinction  between  this  and  the  truly 
purulent  form,  in  which  the  serum  contains  such  a  quantity  of  pus- 
corpuscles  that  it  is  thick,  yellowish,  or  greenish  yellow.  The  term 
empyema  is  applied  to  a  purulent  collection  in  the  thoracic  cavity. 
Primary  empyema  is  a  very  rare  event,  and,  when  it  does  exist,  signifies 
the  admission  of  air  or  some  foreign  matter  to  the  cavity.  The  exuda- 
tion is  at  first  sero-fibrinous,  and  becomes  purulent,  usually  not  until 
after  the  first  week.  There  takes  place,  under  conditions  not  now 
understood,  a  remarkable  production  of  pus-cells — probably  by  enor- 
mously rapid  proliferation  of  the  leucocytes  which  have  wandered 
from  the  vessels.  While  the  serous  fluid  has  an  alkaline  reaction,  the 
purulent  exudation  is  acid  in  reaction.  Often  the  color  of  the  exuda- 
tion is  reddish  from  the  presence  of  red-blood  corpuscles  in  consider- 
able numbers.  But  this  is  not  the  hcemorrhagic  exudation,  properly. 
This  consists  of  blood  derived  from  the  newly  formed,  thin-walled  ves- 
sels of  the  exudation  undergoing  organization,  A  vessel  giving  way, 
the  blood  is  poured  out  (or  there  is  a  diapedesis  of  the  red  globules) 


PLEURITIS.  307 

between  the  layers  of  the  exudation  and  bursts  through  into  the  cavity 
of  the  pleura,  and,  mixing  with  "the  serum,  forms  a  bloody  fluid.  The 
hcemorrhagic  form  of  pleuritis  is  usually  tubercular  in  origin,  or  rather 
is  due  to  the  deposit  of  miliary  tubercle  exciting  a  recurring  inflam- 
mation. An  exudation  may  be  ha^morrhagic  when  the  pleuritis  occurs 
in  an  individual  having  the  haemorrhagic  diathesis,  or  who  is  the  sub- 
ject of  purpura. 

The  evil  results  of  effusions  are  not  limited  to  the  affected  mem- 
brane. When  the  quantity  is  suflicient  to  displace  the  neighboring 
organs,  various  functional  disturbances  arise  from  the  compression. 
At  first  the  lung  retracts  before  the  effusion,  and  only  suffers  by  pres- 
sure when  the  eft'usion  attains  a  certain  volume  sufficient  to  counter- 
balance its  elasticity.  As  the  fluid  increases  from  below  upward,  the 
lung  at  first  floats  ;  but  gradually  the  expansibility  declines,  less  and 
less  air  enters,  and  the  organ  is  finally  flattened  against  the  spine  about 
its  roots.  It  then  appears  as  a  grayish,  bluish,  or  reddish-gray,  rather 
solid  and  flattened  mass,  about  the  size  and  shape  of  the  adult  hand 
without  the  fingers.  It  contains  no  air,  is  bloodless,  and  may  be  coated 
with  a  membranous  exudation,  or  may  be  bound  down  by  membranous 
bands.  If  adhesions  exist,  the  lung  will  be  compressed  in  part,  or, 
if  the  organ  is  infiltrated  by  caseous  or  other  deposits,  the  fluid  will 
act  on  those  parts  that  yet  remain  compressible.  The  fluid  may  be 
collected  in  secondary  cavities,  and  compression  be  confined  to  those  sit- 
uations. The  blood  being  forced  out  of  the  lung,  when  the  organ  is 
flattened  against  the  spine,  distends  the  right  cavities,  which  may  dilate, 
and  fills  the  sound  lung,  which  may  become  congested  and  oedematous. 
If  the  effusion  occupies  the  right  cavity,  the  heart  is  forced  toward 
the  left  side,  the  diaphragm  is  pushed  down,  enlarging  the  capacity  of 
the  right  thorax,  and  displacing  the  liver  downward  ;  if  the  left  cavity, 
the  heart  is  forced  over  to  the  right,  the  diaphragm  is  pushed  down 
to  a  less  extent  than  on  the  right  side,  enlarging  the  left  thorax,  and 
displacing  the  spleen  downward.  The  intercostal  muscles  become  in- 
filtrated, weakened,  and,  yielding  to  the  pressure,  assume  a  convex 
instead  of  a  concave  shape,  the  thorax  being  globular  and  increased 
in  circumferential  and  diametrical  measurement.  If  absorption  take 
place  and  the  lung  is  not  adherent,  the  air  will  again  distend  the  alveoli, 
and  the  thorax  assume  its  normal  shape  ;  if  the  lung  can  expand  again 
only  in  part,  under  the  force  of  the  atmospheric  pressure,  there  will  take 
place  a  depression  of  the  ribs  and  distortion  of  the  spine  to  efface  the 
portion  of  the  cavity  which  the  lung  can  not  fill. 

When  there  is  present  purulent  or  ichorous  exudation  in  the  thorax, 
the  pleura  will,  if  long  exposed  to  its  action,  undergo  necrosis,  and 
a  canal  may  be  tunneled  through  the  lung  into  a  bronchus,  and  through 
this  there  may  be  more  or  less  discharge,  and  a  cure  be  ultimately 
effected.     Caries  of  a  rib  may  follow  necrosis  of  a  portion  of  the  cos- 


308  DISEASES  OF  THE  RESPIKATORY  ORGANS. 

tal  pleura,  and  a  fistulous  communication  be  opened  up  externally,  tlie 
pus  draining  off,  a  cure  being  ultimately  effected,  or  tbe  prolonged 
suppuration  may  lead  to  tubercular  deposit  or  to  amyloid  degeneration 
of  the  organs.  A  fatal  peritonitis  is  in  rare  instances  lighted  wp  by 
the  passage  of  ichorous  matters  through  the  agency  of  the  lymphatics 
of  the  diaphragm.  In  other  cases  a  fistulous  communication  is  estab- 
lished, and  the  pus  dissects  downward  along  the  psoas  muscle,  pointing 
under  Poupart's  ligament,  or  opens  about  the  umbilicus,  etc.  Again, 
the  pus  may  ulcerate  into  the  mediastinum,  into  the  pericardium,  or 
into  the  great  veins,  but  these  are  excessively  rare  accidents. 

Chronic  j^^^urisi/  differs  only  in  time  and  extent  from  the  acute 
form.  In  ^^^^uritis  deformans  the  exudations  are  of  great  thickness 
and  extent,  and,  by  adhesion  and  subsequent  contraction,  extensive 
deformity  of  the  lung  may  result.  The  space  left  between  the  ribs 
and  the  lung  will  be  filled  with  fluid,  and,  as  the  pleura  is  damaged  so 
that  absorption  can  not  take  place,  encapsulation  may  hold  the  fluid 
months,  even  years.  Often,  indeed,  the  false  membrane  which  has 
become  organized  possesses  the  power  of  pus-forming  (pyogenic  mem- 
brane), fistulous  communications  are  established,  and  matter  is  dis- 
charged for  years  even.  The  chest  becomes  greatly  deformed  by 
shrinking,  the  shoulder  depressed,  the  spine  curved,  and  the  heart 
pushed  aside  and  permanently  fixed  in  its  new  position. 

Symptoms. — The  symptomatology  of  pleurisy  varies  with  the  form. 
As  dry  2>l&urisy  is  the  simplest  form,  it  will  be  best  to  consider  it  first. 
This  may  set  in  with  chilliness,  fever,  pain  in  the  side,  and  dyspncea, 
but  more  frequently  there  is  little  or  no  fever,  no  respiratory  disturb- 
ance, only  the  pain  in  the  side  to  indicate  the  nature  of  the  attack.  If 
the  former  symptoms  are  present,  they  do  not  continue  longer  than 
thirty-six  to  forty-eight  hours  ;  if  the  latter,  the  symptoms  rarely  ne- 
cessitate confinement  to  bed.  The  physical  signs  of  dry  pleurisy  are 
as  follows  :  On  inspection,  the  extent  of  the  inspiratory  movement  is 
seen  to  be  lessened  by  the  pain — ^is  aiTested  midway  by  a  sudden  start, 
and  the  body  is  curved  a  little  to  the  affected  side  to  avoid  pressure 
on  the  inflamed  membrane.  On  percussion,  there  is  no  change  in  the 
sonority  from  the  noraial  minimum,  because  of  the  limited  movement 
in  insj)iration,  and  if  the  pain  is  slight  there  will  be  no  change  in  the 
normal  maximum.  On  auscultation,  the  respiration  will  be  feeble  on 
the  affected  side,  because  of  the  pain  elicited  by  the  expansion  in  in- 
spiration ;  and,  if  the  pain  is  severe,  the  inspiratory  murmur  is  rather 
suddenly  arrested  before  completion,  but  if  the  pain  is  slight  there 
will  be  no  change  in  this  respect.  During  the  first  two  or  three  days, 
there  will  be  audible  on  auscultation  a  sound  due  to  the  rubbing  to- 
gether of  the  roughened  surfaces  of  the  pleura — a  friction  or  to-and- 
fro  ridjibing  sound — synchronous  with  the  respiratory  movements,  and 
ceasing  when   they  are  arrested.     If  strong  and  loud,  this  friction- 


PLEURITIS.  309 

sound  produces  a  vibration  of  the  chest-walls,  or  fremitus,  which  is 
recognizable  on  palpation.  Dry  pleurisy  terminates  in  two  ways — by 
resolution,  or  by  adhesion.  "When  resolution  takes  place,  the  pain  and 
fever  subside,  and  the  friction  murmur  gradually  lessens,  and  finally 
disappears.  At  the  apex,  the  friction  murmur  modifies  into  a  leather- 
creaking  sound,  persists,  and  may  be  confounded  with  the  crackling 
rales  which  accompany  the  first  stage  of  tubercular  deposition — a  mis- 
take all  the  more  likely,  since  pleuritic  attacks  are  invited  to  the  apex 
by  the  irritation  of  tubercle.  Dry  pleurisy  occurs  at  the  side  and 
base  of  the  thorax.  This  is  the  origin  of  the  adhesions  found  after 
death,  consisting  of  firm,  strong  bands  of  connective  tissue,  and  which 
excited  no  symptoms  that  attracted  attention.  These  bands  often  do 
serious  mischief  by  limiting  the  movements  of  the  lung. 

Acute  pleurisy  with  effusion,  the  ordinary  form,  sets  in  as  any 
other  acute  inflammation,  with  chill,  general  malaise,  and  fever,  with 
pain  in  the  side  ;  or  there  is  in  other  cases,  for  several  days,  a  daily 
paroxysm  of  fever,  but  without  any  local  symptom  for  the  first  few 
days  ;  or,  again,  there  are  cases  in  which  pain  in  the  side  and  effusion 
have  preceded  the  febrile  movement.  Less  often  than  pneumonia  is 
pleurisy  announced  by  a  decided  chill ;  more  frequently  there  is  chilli- 
ness recurring  irregularly  for  the  first  few  days.  The  fever  which 
follows  is  a  continued  fever,  Avith  an  evening  exacerbation,  and  con- 
tinues up  to  the  beginning  of  the  effusion,  or  about  eight  days,  with 
little  variation.  If  there  are  rigors  occurring  every  day,  although 
irregularly,  and  persist,  it  is  probable  that  the  effusion  is  purulent,  or 
that  the  pleuritis  is  tubercular.  The  type  of  fever  is  not  peculiar  to 
the  disease,  and  is  not  therefore  diagnostic  ;  the  temperature  does  not 
often  exceed  104°  Fahr.,  and  ranges  from  101°  to  the  former  point. 
The  pain  is  usually  acute,  lancinating,  circumscribed,  and  is  increased 
by  breathing,  coughing,  or  abrupt  movements  of  the  body.  It  is  felt 
in  the  outer  and  inferior  portion  of  the  mammary  region,  sometimes 
at  the  base  of  the  thorax,  occasionally  in  the  lumbar  and  iliac  junction, 
and  over  a  space  which  may  be  covered  with  a  finger  or  two.  It  is 
commonly  designated  "a  stitch  in  the  side."  Instead  of  being  cir- 
cumscribed, it  may  be  diffused  and  ill-defined.  The  duration  of  the 
pain  is  variable  ;  it  may  cease  in  three  or  four  days  ;  it  may  reappear 
after  having  ceased  for  a  time  ;  it  may  persist  throughout  the  attack, 
and  so  long  as  it  is  present  it  affords  evidence  of  the  persistence  of  the 
inflammation.  The  severity  and  tenacity  of  the  pain  indicate  the  vio- 
lence of  the  disorder.  Dyspnoea  is  also  a  prominent  symptom  in 
pleuritis.  Several  factors  are  concerned.  When  the  pain  is  severe, 
the  inspiration  is  suppressed,  shallow,  and  frequent ;  hjematosis  is  ac- 
cordingly impaired,  and  respiration  is  embarrassed  from  this  cause. 
Fever,  by  increasing  the  waste  of  tissue  and  the  excretion  of  carbonic 
acid,  augments  the  necessity  for  oxygen.     When  effusion  occurs,  the 


310  DISEASES  OF  THE  RESPIRATORY  ORGANS. 

respiratory  field  is  narrowed,  and  mechanical  difficulties  are  created 
by  the  pressure.  The  decubitus  of  the  patient  is  highly  characteristic. 
Before  effusion  has  taken  place,  the  position  on  the  sound  side  is 
easier,  for,  as  Traube  has  pointed  out,  the  blood  gravitates  from  the 
diseased  side,  and  thus  relieves  the  nerves  of  pressure  ;  but,  when  the 
effusion  begins  to  compress  the  lung,  the  position  on  the  diseased  side 
becomes  the  easier.  When  there  is  extreme  pressure,  the  patient  can 
not  lie  down,  and  hence  seeks  rest  in  the  semi-erect  posture.  More  or 
less  cough  is  present  in  pleuritis,  and  from  the  beginning.  It  is  a  sup- 
pressed cough,  and  is  arrested  in  the  act  of  inspiration  by  the  catching 
pain  in  the  side,  and  is  again  suddenly  arrested  in  the  explosion  on  ac- 
count of  the  pain  given  by  the  shock.  When  effusion  comes  on,  the 
cough  declines,  but  when  there  is  considerable  effusion  cough  is  in- 
duced by  the  attempt  to  take  a  full  inspiration,  or  by  change  of  posi- 
tion. The  expectoration  consists  only  of  a  little  frothy  mucus,  unless 
bronchitis  coexists,  which  is  not  unusual.  As  there  are  anorexia  and 
more  or  less  interference  with  digestion  in  all  febrile  diseases,  the 
waste  of  tissue  proceeds  rapidly — on  one  side  insufficient  supply,  on 
the  other  increased  oxidation.  Emaciation,  loss  of  strength,  with  the 
accompanying  depression  of  the  nervous  system,  are  prominent  among 
the  objective  symptoms  in  pleuritis.  The  countenance  has  an  expres- 
sion of  weariness,  anxiety,  and  exhaustion,  and  may  be  pale  or  cya- 
nosed.  The  cyanosis  is  present  if  there  is  much  orthopnoea  ;  but 
there  may  be  more  or  less  pallor,  possibly  significant  of  hsemorrhagic 
pleuritis,  especially  if  it  occurred  suddenly.  The  urine  is  scanty,  high- 
colored,  has  high  specific  gravity,  and  deposits  urates  abundantly. 

Although  the  rational  symptoms  of  pleuritis  are  very  significant, 
they  are  not  so  precise  and  definite  as  the  physical  signs.  Having 
described  the  former,  we  will  now  take  up  the  latter.  On  inspection, 
the  movements  of  the  affected  side  are  seen  to  be  restricted,  to  be  sud- 
denly arrested,  and  with  an  expression  of  pain.  When  effusion  is 
present,  an  enlargement  of  the  affected  side  is  discerned  ;  the  inter- 
costal spaces  are  less  concave,  are  elevated  to  a  level  of  the  ribs,  even 
rise  above  them,  and  no  movement  takes  place  in  respiration,  while  the 
healthy  side  is  abnormally  active.  On  palpation,  the  absence  of  vocal 
fremitus  is  a  very  important  and  significant  symptom.  The  fremitus 
of  the  voice  is  lessened  as  the  effusion  rises,  to  be  entirely  absent  when 
the  chest  is  distended.  On  the  sound  side  the  vocal  fremitus  is  exag- 
gerated. When  the  effusion  is  large,  on  palpation  there  maybe  fluctu- 
ation detected  in  thin  subjects  ;  by  tapping  one  side  smartly,  a  wave 
traverses  the  liquid  and  is  felt  on  the  opposite  side.  The  character  of 
Xh^  percussion-wot^  is  much  affected  by  the  quantity  of  liquid  present. 
When  there  is  a  moderate  amount  of  effusion,  the  tension  of  the  lung 
is  increased  and  consequently  the  note  is  high-pitched,  rather  hard, 
and  having  a  distinct  tympanitic  quality.     The  tympanitic  and  high- 


PLEUEITIS. 


311 


pitch  quality  of  the  note  is  pai'ticularly  evident  on  percussion  of  the 
infra-clavicular  region,  while  the  note  becomes  deeper  and  harder  over 
the  inferior  and  dependent  parts  where  the  effusion  gravitates.  So 
different  are  the  pitch  and  quality  of 
the  percussion-note  in  the  infra-cla- 
vicular region  of  the  diseased  and  the 
healthy  side,  that,  if  the  examination 
be  carelessly  made,  the  latter  region, 
having  none  of  the  tympanitic  quali- 
ty, will  appear  to  be  diseased.  When 
the  fluid  accumulates  so  that  the  lung 
is  covered  by  a  layer  of  fluid,  two 
inches  in  depth,  the  percussion-note 
will  be  dull  all  over  the  chest,  except 
at  the  sterno-clavicular  articulation, 
where  the  note  will  still  be  high- 
pitched  and  tympanitic,  although 
somewhat  dull.  There  will  be  abso- 
lute dullness  over  the  whole  of  the 
affected  side,  except  j)osteriorly  over 
the  root  of  the  lung,  when  the  cavity 
is  full  and  the  lung  flattened  against 
the  spinal  column.  Exception  should 
also  be  made  of  a  jjoint  correspond- 
ing to  the  junction  of  the  second  rib  with  the  sternum,  where  a  tym- 
panitic note—le  bruit  de  pot  /e/e— indeed,  is  obtained  by  vibration  of 
the  column  of  air  in  the  primary  bronchus  and  trachea  ;  but  in  both 
situations  a  high  pitch  and  hard  quality  are  the  characteristics,  if  the 
lung,  is  entirely  flat  provided  the  percussion  be  lightly  made,  so  as  not 
to  develop  the  tympanitic  quality  obtained  from  the  trachea  and  bron- 
chus. The  value  of  the  percussion-note  is  increased  by  the  absence  or 
presence  of  a  sense  of  resistance.  When  there  is  fluid  in  the  thorax, 
the  sense  of  touch  receives  a  different  impression  from  that  produced 
by  the  normal  condition.  The  diagnosis  of  effusion  in  the  left  thoracic 
cavity  is  much  facilitated  by  an  attentive  examination  of  the  character 
of  the  dullness  in  the  left  hypochondrium.  Owing  to  the  shelving  mar- 
gin of  the  lung,  but  especially  to  the  proximity  of  the  stomach  and  large 
intestine,  the  inferior  portion  of  the  left  lung  returns  a  rather  higher 
pitched  and  tympanitic  note  on  percussion  than  the  portion  above. 
This  space  is  about  two  to  three  inches  in  width  at  the  lateral  border 
of  the  chest,  narrowing  to  nothing  at  either  extremity.  When  fluid 
forms,  the  diaphragm  descends  by  pressure,  and  this  space  is  gradually 
encroached  on,  and  in  the  case  of  large  effusion  disappears.  In  the 
first  stage  of  pleuritis  the  respiration  is  jerking,  and  on  the  affected 
side  the  lung  is  imperfectly  filled  with  air.     On  aiiscidtcUion  these 


Fig.  22.— Limited  Effusion  and  much  Fibrin- 
ous Exudation.    (Da  Costa.) 


312  DISEASES   OF   THE   RESPIRATORY   ORGANS. 

characteristics  of  the  breathing  are  ascertained  —  inspiration  has  a 
catching  or  jei'king  impulse,  and  hence  the  inspiratory  vesicular  mur- 
mur is  feeble,  because  the  lung  can  not  be  filled  with  air.  When  the 
membrane  becomes  rough,  a  rasping,  grating  murmur,  audible  with 
both  insiDU'ation  and  exjjiration — a  to-and-fro  friction  murmur — is  pro- 
duced ;  it  is  synchronous  with  the  respu-atory  movements  and  ceases 
when  they  are  arrested.  It  may  be  so  loud  and  strong  as  to  produce 
a  friction  fremitus,  and  to  be  heard  away  from  the  chest-wall.  It  be- 
comes feeble  as  the  effusion  increases,  and  then  disappears,  to  recur 
again  for  a  short  period  after  the  fluid  is  absorbed.  With  the  increase 
of  the  fluid  in  the  chest,  the  vesicular  murmur  becomes  more  and 
more  feeble  and  then  ceases,  and,  when  it  is  no  longer  audible  at  the 
base,  may  be  heard  above  the  line  of  effusion  and  of  dullness.  When 
the  lung  is  compressed  but  the  bronchi  are  still  permeable,  and  the 
body  of  fluid  not  too  great,  the  breathing  has  the  bronchial  character, 
and  has  no  vesicular  quality.  When  the  lung  is  flattened  against  the 
spine,  no  breathing-sounds  of  any  kind  remain.  Similarly,  hronchial 
voice,  or  'bronchophony,  is  audible  from  the  still  pervious  bronchial 
tubes,  as  is  the  bronchial  breathing,  but  this  ceases  as  the  correspond- 
ing breath-sound  does,  and  no  voice-sound  remains,  ^gophony,  or 
goat's  voice,  is  a  modification  of  bronchial  voice  supposed  at  one  time 
to  be  produced  by  the  vibrations  of  a  rather  thin  stratum  of  fluid, 
interposed  between  the  chest- wall  and  the  lung,  but  it  is  now  regarded 
as  a  simple  modification  of  broncophony.  With  the  disappearance  of 
the  effusion  the  lung  expands,  and  there  is  a  gradual  diminution  of  the 
dullness,  until  the  percussion-note  becomes  normal  and  the  resistance 
declines  correspondingly.  The  vocal  fremitus  is  restored  in  the  same 
order.  The  voice  and  breath  sounds  are  at  first  bronchial,  then  gradu- 
ally become  vesicular.  As  the  bronchial  voice  and  breath-sounds  be- 
come audible,  the  friction-sound  appears  and  continues  up  to  the  full 
restoration  of  the  vesicular.  Besides  the  friction  to-and-fro  sound, 
there  are  often  heard,  after  the  disappearance  of  the  liquid  effusion, 
coarse,  creaking,  grating  sounds,  which  appear  to  be  produced  by  the 
stretching  of  bands  of  adhesion,  or  the  rubbing  together  of  the  large 
masses  of  solid  exudation  yet  remaining  for  absorption.  The  author 
has  witnessed  the  development  and  gradual  disappearance  of  these 
sounds,  during  many  months  after  recovery.  Besides  these  sounds, 
rales,  rather  coarse,  sub-mucous,  and  sub-crepitant,  are  audible  during 
the  process  of  absorj^tion,  and  were  supposed  to  be  due  to  changes  in 
the  pulmonary  parenchyma,  but  are  now  known  to  be  produced  by  the 
opening  up  of  tubes  long  compressed.  Besides  these,  rdles  are  present 
in  cases  of  acute  pleuritis,  because  of  an  accompanying  bronchitis. 

Course,  Duration,  and  Termination. — Pleurisy  does  not  pursue  a 
defined  course,  nor  does  it  terminate  in  crisis,  which  is  the  normal 
mode  for  pneumonia,  but  under  favorable  circumstances  the  develop- 


PLEURITIS.  313 

ment  is  gradual,  and  the  return  to  health  is  by  slow  stages.  Begin- 
ning in  some  one  of  the  modes  described,  the  fever  regularly  increases 
for  the  first  four  or  five  days,  and  then  continues  for  'eight  or  nine 
days  pretty  constantly  at  a  uniform  height.  Then  comes  the  period 
of  effusion,  when  the  temperature  falls,  the  pain  subsides,  and  the 
dyspnoea  diminishes  unless  there  is  a  large  effusion,  when  the  diffi- 
culty of  breathing  is  proportional  to  the  amount  of  comj^ression  to 
which  the  lung  is  subjected.  The  length  of  the  time  the  effusion 
continues  at  its  maximum  varies  from  one  day  to  five.  The  absorp- 
tion may  take  place  quite  rapidly  at  first,  but  it  does  not  continue  at 
the  same  rate  after  the  first  two  or  three  days.  The  reason  is,  prob- 
ably, because  the  liquid  part  of  the  exudation  is  more  easily  disposed 
of,  the  solid  portion  needing  to  undergo  a  fatty  transformation  to  fit 
it  for  absorption.  The  rate  of  absorption  is  measured  by  the  gradual 
return  of  the  normal  sounds,  by  the  diminution  of  the  dullness,  and 
by  the  movement  of  displaced  organs  to  their  proper  positions.  The 
changes  in  the  condition  of  the  inflamed  parts  are  represented  in  the 
improved  appearance,  better  appetite,  and  increasing  strength.  A 
marked  change  takes  place  in  the  urinary  secretion,  which  becomes 
more  abundant,  less  highly  colored,  and  contains  for  a  brief  period 
cast-off  eiDithelium  and  a  trace  of  albumen.  The  absorption  of  the 
last  part  of  the  exudation  is  exceedingly  slow,  and  months,  even  a 
year  or  two,  may  elapse  before  the  physical  signs  indicate  complete 
restoration.  The  return  toward  health  is  often  interrupted  by  fresh 
attacks  of  inflammation,  by  a  new  outpouring  of  effusion,  by  an  acces- 
sion of  fever  and  respiratory  disturbance.  Additional  inflammation  of 
the  pleura  and  of  the  neo-membranes  arrests  the  process  of  absorption, 
depresses  the  vital  forces,  and  prepares  the  way  to  the  chronic  state, 
yet  it  sometimes  happens  that  the  new  excitement  awakens  renewed 
activity  in  the  process  of  absorption,  which  goes  on  more  rapidly 
afterward.  If,  after  the  twenty-fifth  to  the  thirtieth  day,  there  is  no 
appreciable  diminution  in  the  state  of  the  effusion,  the  acute  stage 
ends  and  the  chronic  begins.  It  maybe  that  the  effusion  remains 
stationary,  and  the  general  condition  continues  good  ;  in  other  cases 
grave  symptoms  may  arise,  the  temperature  may  increase,  and  in  a 
day  or  two  attain  to  the  maximum  of  the  first  two  weeks,  or  pass 
beyond  it  ;  rigors  may  occur  irregularly,  followed  by  paroxysms  of 
fever  and  sweats  ;  the  countenance  becomes  anxious  ;  the  tongue  dry  ; 
the  depression  great — without  there  being  any  change  in  the  extent 
of  the  effusion  or  any  new  complication.  This  grave  change  in  the 
condition  of  the  patient  is  due  to  the  purulent  transformation  of  the 
exudation.  It  has  already  been  indicated  that  the  exudation  may  be 
purulent  from  the  beginning,  and  that  under  these  circumstances  the 
symptoms  have  at  the  outset  the  septicaemic  character  above  described. 
The  termination  is  in  resolution;  in  the  chronic  form  ;  in  death.    The 


314  DISEASES   OF   THE   EESPIRATORY   ORGANS, 

average  duration  of  an  acute,  uncomplicated  case  is  two  to  four  weeks. 
Death  may  occur  within  the  first  two  weeks,  in  the  so-called  fulminant 
form,  or,  when  there  is  a  very  extensive  sero-fibrinous  efi^usion  causing 
fatal  syncope,  most  probably  by  compression  of  the  great  venous 
trunks,  especially  of  the  ascending  vena  cava,  which  may  be  twisted 
and  its  lumen  obstructed  by  displacement  of  the  heart.  Again,  oedema 
of  the  sound  lung  may  suddenly  ensue  as  a  result  of  compression  of 
its  fellow,  and  cause  death.  An  early  recovery  from  pleuritis  with 
effusion  signifies  that  the  effusion  must  have  been  of  small  extent. 
Any  large  inflammatory  effusion,  especially  if  the  solid  portion  of  it  is 
considerable,  must  require  a  long  time,  months  certainly,  to  dispose 
of  it  entirely. 

Chronic  pleurisy  is  an  outcome  of  the  acute  disease,  or  it  occurs 
primarily.  It  differs  from  the  acute  merely  in  the  severity  and  chro- 
nicity  of  the  symptoms.  The  fever  is  slight,  the  pain  is  not  severe, 
but  yet  extensive  changes  will  take  place  in  the  pleura.  When  the 
characteristic  anatomical  alterations  have  been  effected,  there  will  be 
fever  of  the  septicaemic  type.  The  rational  and  physical  signs  are  the 
same  as  those  of  the  acute  form.  The  duration  of  the  cases  varies 
from  two  or  three  months  to  several  years.  Attempts  at  absor2Dtion 
going  on  favorably  may  be  stopped  by  a  new  inflammation  of  the 
pleura,  and  of  the  neo-membranes  with  more  effusion.  An  effusion 
that  has  remained  stationary  for  a  long  time  may,  unexpectedly,  un- 
dergo absorption  by  reason  of  the  development  of  vessels  in  the  new 
formations.  But  a  cure  by  absorption  is  rare  ;  there  are  usually  incom- 
plete absorption,  retraction  and  deformity  of  the  chest,  and  permanent 
displacement  of  organs,  or  an  external  fistula,  occurring  spontaneously 
or  resulting  from  an  operation,  may  produce  a  favorable  result  com- 
paratively. Without  the  operation  of  paracentesis,  chronic  pleurisy 
usually  proves  fatal  by  tuberculosis,  by  purulent  infection,  or  by  pene- 
tration of  the  pus  into  neighboring  cavities,  etc. 

Complications. — The  inflammation  may  extend  by  contiguity,  and 
attack  the  pericardium — a  not  uncommon  complication.  There  will 
occur  a  fibrino-serous  exudation,  often  of  considerable  extent.  The 
lung  may  be  involved,  but  pneumonia  is  rather  a  coexisting  disease — 
pleuro-pneumonia — than  a  complication.  It  is  important  to  note  that 
the  lung  on  the  sound  side  may  be  affected  by  oedema,  a  complication 
which  adds  immensely  to  the  gravity  of  the  case.  Not  only  is  the 
organ  oedematous,  but  it  usually  presents  patches  of  commencing  pneu- 
monic infiltration.  The  importance  of  pleuritis  as  a  cause  of  phthisis 
is  hardly  sufficiently  recognized,  in  inducing  tubercular  deposit,  and 
by  adhesions  limiting  the  movements  of  the  organ,  and  thus  inducing 
disease. 

Diagnosis. — The  most  important  difficulties  in  diagnosis  are  expe- 
rienced in  the  differentiation  of  pleurisy  with  effusion  from  conditions 


PLEURITIS.  315 

in  which  the  hing  is  solidified  or  is  displaced  by  tumors,  cysts,  etc. 
Pleurisy  is  distinguished  from  croiq^oiis  jmezimonia  by  reference  to 
the  rational  and  physical  signs.  Pleurisy  begins  by  chilliness,  which 
persists  for  several  days — pneumonia  by  a  severe  rigor,  rarely  two  ; 
the  pain  in  pleurisy  is  a  stitch,  a  lancinating  pain,  which  can  be  cov- 
ered by  the  finger — pneumonia  by  a  sense  of  soreness  and  pain  much 
more  diffused  ;  the  fever  in  pleurisy  is  continuous — in  pneumonia  there 
is  a  distinct  crisis  or  lysis,  somewhere  from  the  fifth  to  the  eleventh 
day  ;  the  duration  of  pleurisy  is  indefinite — of  pneumonia  self -limited  ; 
the  expectoration  in  pleurisy  is  simply  frothy  mucus — of  pneumonia, 
rusty  or  bloody  ;  in  pleurisy  the  vocal  fremitus  is  absent — in  pneumo- 
nia it  is  not  only  present  but  exaggerated  ;  in  pleurisy  there  is  a  fric- 
tion-sound, no  crepitant  rale,  and  the  bronchophony  is  not  so  well 
defined — in  pneumonia  there  is  no  friction-sound,  the  crepitant  rctle  is 
present,  and  broncophony  is  loud  and  clear  ;  in  pleuritis  there  is  more 
decided  dullness,  the  intercostal  spaces  are  pushed  out,  the  thorax  en- 
larged— in  pneumonia  the  percussion-note  is  not  so  flat,  the  intercostal 
spaces  and  the  size  of  the  thorax  remain  normal ;  in  pleuritis  the 
organs  are  displaced  ;  in  pneumonia  the  relation  of  the  organs  is  un- 
affected. Finally,  the  subsequent  behavior  of  pneumonia  and  pleuritis 
leaves  no  room  for  doubt.  An  abscess  of  the  liver  pushing  up  the 
diaphragm,  or  an  echinococcus-cyst  growing  in  the  same  direction,  of 
suflicient  size  ,to  displace  the  lung  in  the  same  way,  will  cause  the 
physical  signs  of  an  effusion  into  the  thorax,  and  the  diagnosis  is  pos- 
sible only  by  a  careful  study  of  the  history,  which  is  entirely  different 
in  the  two  affections.  A  tumor  or  cyst  of  the  chest  will  produce  dull- 
ness on  percussion,  displace  organs,  and,  by  compressing  the  lungs 
cause  the  disappearance  of  the  voice  and  breath  sounds.  The  differen- 
tiation is  to  be  made  by  reference  to  the  history  of  the  cases,  by  the 
situation  of  the  dullness  toward  or  about  the  central  and  superior  parts 
of  the  chest  in  tumor — the  inferior  part  of  the  chest  in  effusion  ;  by 
the  general  and  symmetrical  bulging  of  the  chest-walls  in  effusion,  the 
circumscribed  and  irregular  bulging  caused  by  tumor  ;  by  the  absence 
of  vocal  fremitus  in  pleuritis — its  exaggeration  in  cases  of  tumor. 

Although  the  withdi-awal  of  the  fluid  is  the  only  certain  means  of 
arriving  at  the  nature  of  the  effusion,  there  are  signs  by  which  we  may 
approximate  with  considerable  accuracy  to  a  correct  diagnosis.  If, 
during  the  acute  stage,  the  fever  running  high,  the  effusion  pouring 
out  rapidly,  there  suddenly  ensue  great  pallor,  weakness,  and  depressed 
temperature,  followed  after  some  hours  by  rise  of  temperature  even 
higher  than  before,  a  haemorrhage  has  probably  occurred  ;  or,  if  during 
the  chronic  stage  there  are  recurrent  attacks,  and  the  above-described 
symptoms  occur,  the  case  is  not  only  hemorrhagic,  but  the  underlying 
morbid  process  is  tuberculosis.  If  the  case  is  characterized  from  the  be- 
ginning by  repeated  rigors,   occurring  irregularly,   and  followed  by 


316  DISEASES  OF  THE  RESPIRATORY  ORGANS. 

paroxysms  of  intense  fever  and  sweats,  the  exudation  is  purulent ;  if 
during  the  course  of  an  ordinary  attack  of  sero-fibrinous  pleuritis,  the 
same  septicaemic  symptoms  arise,  the  exudation  has  been  transformed 
into  the  purulent. 

Treatment. — The  author  wishes  to  protest  at  the  outset  against  that 
revival  in  the  belief  of  the  aplastic  power  of  mercury,  and  the  return 
to  its  use  in  the  treatment  of  serous  inflammation,  which  is  taking 
place  in  Germany,  and  finds  expression  in  Ziemssen's  "  Cyclopaedia. "  * 
It  has  been  definitely  shown  that,  during  the  course  of  acute  mercu- 
rialismus,  an  attack  of  pleuritis  or  inflammation  of  some  serous  mem- 
brane is  apt  to  occur  in  consequence  of  morbific  matters  circulating 
in  the  blood.  Unless  it  be  established  that  this  effect  of  mercury  is 
substitutive,  there  is  no  ground  for  its  employment,  and  certainly  the 
experience  of  English  physicians  is  opposed  to  the  practice. 

As  soon  as  the  pleuritic  inflammation  begins,  and  the  pain  is  a  good 
indication,  the  patient  should  receive  a  full  dose  of  quinia  and  morj)hia 
(3  j  quinia  and  gr.  ss.  morphia  for  an  adult),  and  the  effect  of  this 
should  be  maintained  by  the  repetition  of  smaller  doses  (gr.  v  quinia, 
■J  gr,  morphia)  every  four  hours.  If  the  stomach  is  irritable,  the  mor- 
phia can  be  administered  subcutaneously,  or,  if  the  pain  is  very  acute, 
this  mode  of  administration  is  more  effective  than  by  the  mouth.  Be- 
sides the  power  of  morphia  to  relieve  pain,  it  is  an  effective  remedy  in 
serous  inflammation.  The  combination  which  was  so  much  employed 
formerly  (calomel  and  opium)  owed  its  virtues  to  the  opium.  If  there 
be  much  fever — a  strong  pulse  and  elevated  temperature — and  the 
stomach  not  irritable,  digitalis  may  be  combined  with  the  quinia  and 
morphia — one  grain  every  four  hours.  If  the  subject  be  plethoric,  a 
dozen  cups  or  leeches,  drawing  six  ounces  of  blood,  can  be  applied  with 
advantage.  The  old  plan  of  bleeding  ad  deliquum  animi  or  until  the 
pain  ceased  was  a  powerful  and  certain  means  of  relieving  pain  which 
has  been  rightly  abandoned,  but  the  local  bloodletting  is  of  service. 
Mustard-plasters  and  turpentine-stupes,  as  hot  as  can  be  borne,  afford 
relief.  The  blood-pressure  can  be  reduced  also  by  active  purgatives,  of 
which  the  salines  are  best.  When  the  exudation  is  poured  out,  a  dif- 
ferent plan  will  be  necessary.  The  only  agents  which  possess  the  prop- 
erty of  dissolving  an  exudation  are  the  alkalies,  and  the  most  efiScient 
of  these  is  ammonia.  Carbonate  of  ammonia  can  be  best  given  in  a 
solution  of  the  acetate  (gr.  v — x  in  3  ss. —  3  j).  They  should  take  the 
place  of  the  quinia  and  morphia.  Absorption  will  be  much  aided  by 
keeping  up  free  outward  osmosis  through  the  intestinal  mucous  mem- 
brane by  saline  laxatives.  The  same  process  can  be  carried  on  through 
the  skin  by  the  use  of  jaborandi  or  its  alkaloid,  pilocarpine.  This  should 
be  administered  once  or  twice  a  day,  but  its  action  on  the  heart  should 

*  Vol,  xiv,  p,  685,  and  elsewhere. 


PLEURITIS.  Sl'^r 

not  be  forgotten,  and  care  exercised  if  there  be  disj)lacment  of  this 
organ,  especially  if  there  be  a  twist  in  the  vena  cava.  The  best  mode 
of  administering  jaborandi  is  the  hypodermatic  injection  of  its  alkaloid, 
pilocarpine — -g  of  a  grain  of  any  of  the  salts.  As  the  pouring  out  of 
60  much  fluid,  the  waste  of  tissue  produced  by  a  high  temperature, 
and  the  interference  with  assimilation  caused  by  the  disordered  diges- 
tion, rapidly  impair  the  vital  forces,  it  is  important,  by  proper  food- 
supply  and  the  judicious  use  of  stimulants,  to  obviate  the  asthenia. 
When,  however,  a  large  effusion  exists,  especially  if  purulent,  it  be- 
comes necessary  to  remove  it  by  the  operation  of  thoracentesis.  Even 
if  absorption  may  eventually  succeed  in  disposing  of  the  fluid,  there  is 
great  danger  that  the  lung  will  not  be  in  a  condition  to  expand  again 
fully,  and  retraction  and  deformity  of  the  chest  will  be  the  result.  If 
the  effusion  be  purulent,  absorption  can  not  take  place,  and  hence 
thoi'acentesis  is  indispensable.  The  question  of  how  early  shall  thora- 
centesis be  performed  has  been  much  discussed.  It  ought  not  to  be 
undertaken  within  a  few  days  after  effusion,  nor  unless  the  symptoms 
of  compression  are  urgent  while  the  exudation  is  going  on.  It  ought 
not  to  be  performed  if  the  natural  powers  are  equal  to  the  task  of  re- 
moving the  fluid  early  enough  to  save  damage  to  the  organs  concerned. 
These  rules  apply  to  the  sero-fibrinous  form  of  pleuritis.  Thoracentesis 
ought  to  be  performed  in  the  purulent  form  as  soon  as  the  nature  of 
the  case  is  evident,  for  nothing  is  to  be  gained  by  delay.  The  point 
of  election  when  the  choice  may  be  made  is  underneath  the  infei'ior 
angle  of  the  scapula,  but  the  needle  may  be  inserted  at  any  place  with 
due  regard  to  the  position  of  the  heart  and  great  vessels.  As  regards 
the  method  of  procedure,  nothing  has  been  added  practically  to  the 
method  of  Bowditch  (the  real  inventor  of  the  aspirateur),  which  con- 
sists in  exhausting  the  chest  by  the  pump  and  attached  needle.  Al- 
though the  admission  of  air  does  not  seem  to  be  very  important,  yet  it 
is  better  to  avoid  it  in  cases  of  the  sero-fibrinous,  for,  if  subsequent 
operations  are  necessary,  the  effusion  will  become  more  and  more  pu- 
rulent. If  this  is  the  case,  the  tincture  of  iodine  or  a  diluted  com- 
pound solution  can  be  injected  with  great  advantage  after  removing  the 
fluid  (liq.  iodinii  comp.  3J — aquae  3  iv).  This  iodine  injection  is  high- 
ly useful  in  empyema,*  Precautions  to  avoid  air  are  usually  regarded 
as  unnecessary  in  the  case  of  purulent  effusion.  In  those  cases  requir- 
ing repeated  tapping,  late  experience  has  shown  that  the  best  results 
are  obtained  by  establishing  free  drainage.  If  a  sufficient  opening  for 
the  drainage-tube  can  not  be  obtained  in  the  intercostal  space,  exsec- 
tion  of  the  rib  is  then  necessary.  The  simplest  of  these  operations 
should  be  jDerforraed  with  antiseptic  precautions.  If  the  pus  of  an 
empyema  undergo  decomposition  and  become  foul,  the  cavity  should 

*  A  warm  solution  of  chlorate  of  potassa  (  3  j  or  3  ij — 0  j)  or  of  salicylic  acid  and 
borax  (  3  j  of  each  to  the  0  j),  may  also  be  used  to  wash  out  the  cavity  in  empyema. 


318  DISEASES  OF  THE   RESPIRATORY   ORGANS. 

be  freely  washed  out  with  antiseptic  precautions.  Although  the  ad- 
mission of  air  in  cases  of  empyema  is  not  sought  to  be  prevented, 
nevertheless  the  air  should  be  deprived  of  its  germs  of  putrefaction. 

As  death  has  occurred  several  times  very  unexpectedly  after  the  op- 
eration of  thoracentesis,  certain  precautions  are  necessary.  When  the 
effusion  is  large,  the  whole  amount  should  not  be  withdrawn  at  once, 
for  the  sudden  removal  of  the  pressure  might  induce  a  quick  outpour- 
ing of  fluid,  or  the  great  vessels,  relieved  of  pressure,  would  over-dis- 
tend the  right  cavities,  or  the  heart,  moving  from  its  position,  might 
cause  compression  of  some  of  the  vessels.  Sudden  death  might  very 
unexpectedly  be  caused  by  any  of  these  accidents,  notwithstanding 
the  operation  of  thoracentesis  is  simple,  not  painful,  and  is  free  from 
danger.  After  the  removal  of  the  liquid  exudation  by  absorption  or 
by  thoracentesis,  a  quantity  of  solid  and  semi-solid  remains  behind 
and  is  very  slowly  transformed.  A  succession  of  flying-blisters,  paint- 
ing with  the  tincture  of  iodine,  and  friction  of  the  affected  side  with 
ointment  of  the  red  iodide  of  mercury,  are  the  most  effective  external 
or  topical  applications.  The  best  results  are  obtained,  not  from  the  use 
of  supposed  stimulants  of  the  absorbents,  but  from  means  to  promote 
the  nutrition.  The  iodide  of  iron  (sirup),  cod-liver  oil,  extract  of 
malt,  and  a  generous  diet,  the  digestion  stimulated  by  bitters  and  min- 
eral acids,  are  the  best  means  for  increasing  absorj)tion.  The  amount 
of  fluid  taken  should  be  reduced  to  the  mir^jmum  ;  for,  although  the 
restrictions  imposed  in  a  "  dry  diet "  may  be  too  rigid  for  ordinary 
patients,  yet  they  can  submit  to  a  considerable  reduction  of  the  fluid. 
Absorption  is  promoted  by  lessening  the  water  of  the  blood,  which 
can  be  accomplished  by  saline  laxatives  and  Jaborandi.  The  laxatives 
should  not  be  given  so  as  to  interfere  with  digestion,  and  a  daily  dose 
of  jaborandi  can  be  so  administered  as  not  to  interfere  with  the  appe- 
tite or  exercise.  To  procure  complete  distention  of  the  lung,  and  to 
promote  the  oxygenation  of  the  blood,  compressed  air  should  be  inhaled 
daily,  or  a  sojourn  in  an  elevated,  dry  mountain-region  should  be  en- 
joined. Although  we  may  not  agree  wath  Dr.  Leaming,  of  New  York, 
in  the  importance  of  pleuritic  exudations  as  a  factor  in  phthisis,  we 
must  admit  that  they  -exercise  some  influence  in  initiating  the  jsrocess 
of  tuberculosis. 


HYDROTHORAX— DROPSY  OF  THE  CHEST. 

Definition. — By  the  term  hydrothorax  is  intended  an  accumulation 
of  watery  fluid  in  the  chest.  It  differs  from  pleuritis  in  the  character 
of  the  fluid  and  in  the  state  of  the  pleura.  In  pleuritis  the  effusion  is 
an  inflammatory  exudation,  and  the  pleura  is  the  seat  of  an  inflamma- 
tion ;  in  hydrothorax  the  fluid  transudes — a  merely  physical  process — 
and  the  pleura  is  unaffected  except  by  maceration. 


HYDROXnORAX.  319 

Causes. — The  various  conditions  giving  rise  to  general  dropsy  will 
cause  hydrotliorax — cai'diac  and  renal  diseases.  Local  obstruction  to 
the  course  of  the  circulation  produces  pure  hydrothorax,  i.  e.,  hydro- 
thorax  not  a  part  of  a  general  dropsy.  The  most  important  of  these 
local  causes  are  emphysema  and  sclerosis  of  the  lung,  tumors  so  situ- 
ated as  to  compress  the  vena  cava,  vena  azygos,  the  right  auricle,  etc. 
A  general  dyscrasia  may  induce  hydrothorax,  as  Bright's  disease,  chronic 
malarial  poisoning,  etc.  The  most  influential  factor  is  the  condition  en- 
titled by  the  older  authors  latent  pleurisy.  In  this  malady  there  is  a 
state  of  the  pleural  membrane  closely  allied  to  pleuritis — to  that  form 
known  as  dry  pleurisy  ;  but  instead  of  a  plastic  exudation  there  is  an 
abundant  outpouring  of  serum. 

Pathological  Anatomy. — When  the  hydrothorax  is  due  to  any  of 
the  causes  producing  general  dropsy,  the  effusion  is  bilateral,  but  usu- 
ally more  abundant  on  one  side.  There  will  be  found  associated  with 
the  hydrothorax  the  anatomical  changes  in  the  lungs,  heart,  and  kid- 
neys, proper  to  the  particular  form  of  dropsy.  The  fluid  has  a  pale 
sea-green  color,  is  transparent,  and  frequently  coagulates  on  exposure 
to  air,  the  coagulation  consisting  in  the  formation  of  an  excessively  fine 
reticulation  of  the  minutest  fibers.  In  the  case  of  the  so-called  latent 
pleurisy  the  membrane  is  thickened,  congested,  and  coated  usually 
with  a  pellicular  exudation,  portions  of  which  are,  to  a  greater  or  less 
extent,  floating  in  the  fluid.  The  amount  of  serum  present  is  from 
half  a  pint  to  two  or  three  gallons.  The  effect  of  the  fluid  on  the  posi- 
tion of  the  heart  and  other  organs  is  precisely  the  same  as  in  pleuritis. 
The  retraction  of  the  lung  and  its  subsequent  compression  also  take 
place,  as  in  pleurisy,  except  that  it  occurs  more  regularly. 

Symptoms. — In  latent  pleurisy,  so  called,  there  is  some  pain  felt  in 
various  parts  of  the  chest,  but  it  is  not  acute  and  well  defined  as  in 
pleurisy.  It  is  usually  situated  in  the  side,  and  is  a  rather  dull,  ten- 
sive, heavy  pain,  or  a  feeling  of  soreness.  It  is  increased  by  a  full 
inspiration,  or  by  coughing,  but  is  not  so  severe  as  to  interfere  with 
daily  duties  ;  and  it  is  often  transient,  and  makes  so  little  impression 
on  the  mind  as  to  be  forgotten  until  attention  is  directed  to  it.  There 
is  some  feverishness  toward  evening,  but  not  much  attention  is  paid  to 
it,  and  hence  it  is  usually  overlooked.  The  cough  may  be  rather  trou- 
blesome, especially  on  lying  down,  but  the  expectoration  is  nothing 
more  than  frothy  mucus.  Often  these  symptoms  pass  unnoticed,  and 
the  first  thing  which  attracts  attention  is  an  increasing  difiiculty  of 
breathing.  In  the  cases  of  hydrothorax  pure,  without  plem-al  inflam- 
mation, there  is  no  fever,  nor  pain  in  the  side,  and  the  first  symptom 
referable  to  the  thorax  is  difiiculty  of  breathing  greater  than  in  pleu- 
risy, because  the  effusion  is  on  both  sides.  In  latent  pleurisy,  the  left 
side  of  the  thorax  is  involved  in  two  thirds  of  the  cases  ;  consequently 
the  heart  is  pushed  over  to  the  right,  and  the  semilunar  space  is  oblit- 


320  DISEASES  OF  THE  RESPIRATORY  ORGANS. 

erated.  In  hydrotliorax  there  is  no  displacement  of  the  organs,  be- 
cause of  the  effusion  on  two  sides  and  in  the  abdominal  cavity.  The 
physical  signs  are  much  the  same  in  hydro  thorax  as  in  pleurisy  ;  but 
in  .the  former  there  can  not  be  that  complete  filling  of  the  cavities,  and 
hence  there  must  be  a  considerable  space  of  both  lungs  where  the  voice 
and  breath  sounds  remain  unaffected.  Furthermore,  in  hydrothorax, 
there  being  no  limitation  of  the  eff usio  n  by  neo-membrane  and  by  ad- 
hesions, the  fluid  gravitates  with  the  changes  of  position,  and  the  area 
of  dullness  shifts  accordingly.  The  course,  duration,  and  termination 
of  hydrothorax  are  those  of  the  disease  on  which  it  depends.  The 
formation  of  a  large  effusion  in  the  chest  adds  to  the  severity  of  the 
case,  and  is  not  unfrequently  a  cause  of  death.  This  is  especially  true 
of  dropsy,  whether  cardiac  or  renal.  The  hydrothorax  is  a  source  of 
extreme  distress  when  it  may  not  prove  fatal,  for  the  patient  is  unable 
to  lie  down,  or  to  make  any  muscular  effort  without  experiencing  a 
suffocative  attack.  The  author  has  witnessed  a  case  of  sudden  death 
from  hydrothorax  in  an  aneurism  of  the  arch  of  the  aorta  which  was 
solidifying.  The  behavior  of  latent  pleurisy  is  that  of  the  sero-fibrin- 
ous  form  of  acute  pleurisy,  when  sufficient  fluid  has  accumulated  to 
produce  symptoms  by  compression. 

Treatment. — If  there  is  large  effusion,  delay  is  unsafe  and  thora- 
centesis should  be  promptly  performed.  As  serum  will  flow  through 
a  fine  capillary  needle,  but  little  pain  and  no  danger  attend  the  opera- 
tion of  aspiration.  If  the  effusion  is  not  sufficient  to  produce  distress 
by  pressure,  the  treatment  is  directed  to  the  condition  on  which  the 
dropsy  depends.  The  treatment  for  latent  pleurisy  is  the  same  as  for 
acute  pleurisy  with  effusion.  As  the  inflammatory  symptoms  are  usu- 
ally overlooked,  the  physician  is  not  consulted  until  the  difficulty  of 
breathing  comes  on,  and  then  the  sole  question  is,  aspiration  or  not. 
The  rules  for  guidance  are  the  same  as  those  already  laid  down. 


PNEUMOTHORAX— HYDROPNEUMOTHORAX. 

Deflnition. — The  presence  of  air  in  the  cavity  of  the  thorax  is 
cSiWed  pneiwiothorax/  of  air  and  fluid,  liydropneumotliorax. 

Causes. — Air  or  gas  of  any  kind  is  rarely  present  in  the  cavity 
without  liquid,  and  if  air  alone  should  enter  an  exudation  would  soon  be 
excited.  It  is  now  settled  that  a  serous  membrane  can  not  secrete  air, 
and  that,  therefore,  if  air  be  found  in  the  cavity  of  the  pleura,  it  came 
there  from  without,  or  is  a  gas  the  product  of  decomposition  or  fer- 
mentation. Almost  always  it  enters  from  without  by  perforation  of 
the  pleura,  by  the  lung,  or  by  the  wall  of  the  thorax.  The  most  fre- 
quent mode  of  entrance  of  air  is  the  giving  way  of  a  superficial  cavity 
of  the  lung,  tubercular  or  caseous.  Very  rarely  the  air  passes  through 
a  communication  made  by  a  gangrene  patch,  or  a  hremorrhagic  infarc- 


PNEUMOTHORAX.  321 

tion,  and  still  more  rarely  by  the  giving  way  of  emphysematous  alveoli. 
Abscesses  of  the  liver  ulcerating  through  the  diaphragm  may  form  a 
secondary  purulent  collection  in  the  pleural  cavity,  which  may  com- 
municate through  the  lung  with  a  bronchus,  constituting  pyopneumo- 
thorax. One  of  the  modes  of  termination  of  a  purulent  pleuritis  is  by 
a  fistulous  passage  to  a  bronchus,  through  which  air  is  admitted  to  the 
pleura.  Suppuration  may  occur  in  neighboring  organs  in  a  way  to 
involve  the  pleura  and  some  outlet,  as — suppuration  of  bronchial 
glands,  bursting  into  the  pleura  and  ulcerating  into  a  bronchus  ;  ab- 
scesses of  the  liver  or  of  the  kidney,  perforating  the  diaphragm  and 
the  lung,  etc.  Traumatism  is  an  important  factor,  pyopneumothorax 
being  caused  by  penetrating  wounds,  incised  or  gunshot,  the  air  enter- 
ing from  without. 

Pathological  Anatomy. — The  accumulation  of  air  in  a  given  case 
is  much  influenced  by  the  formation  of  the  orifice  of  communication. 
If  the  entrance  is  easy  and  the  exit  difficult,  a  very  large  amount  of  air 
may  accumulate,  and  very  often  a  sort  of  valvular  arrangement,  a 
fibrinous  flap  or  plug,  may  exist  at  the  orifice  which  has  this  effect. 
The  lung  quickly  retracts  until  there  is  an  equilibrium  of  the  pressure; 
com^Dression  is  then  exerted  on  it  if  the  orifice  is  such  that  the  air 
which  entered  without  obstruction  can  not  escape.  The  quantity  of  air 
which  can  be  contained  in  the  cavity  depends  on  several  conditions: 
on  the  compressibility  of  the  lung,  which  may  be  slight  owing  to  so- 
lidification by  caseous  or  tubercular  deposits  ;  the  degree  in  which  the 
other  organs  can  be  shoved  aside  ;  the  amount  of  liquid  present,  etc. 
It  is  a  mixture  of  gases,  not  air,  usually  found  in  the  cavity — of  nitro- 
gen and  carbonic  acid,  and  but  little  oxygen,  with  some  sulphuretted 
hydrogen  if  there  be  unhealthy  pus  present.  If  atmospheric  air  en- 
ters, the  pleura  inflames,  and  sero-purulent,  then  purulent  exudation  is 
poured  out.  As  air  contains  the  bacteria  of  decomposition,  it  is  probable 
that  their  entrance  is  sufiicient  to  excite  purulent  inflammation ;  but,  as, 
in  pneumohydrothorax,  ichorous,  ulcerating,  or  decomposing  materials 
pass  in  under  the  usual  circumstances,  these  play  a  more  active  part  in 
exciting  inflammation  than  the  air  and  its  contained  germs.  The  ex- 
udation which  results  from  the  action  of  these  noxious  matters  is  pu- 
rulent, often  ichorous  and  bloody.  The  gas  is  contained  in  the  space 
above  the  liquid,  and  the  lung,  having  had  the  air  squeezed  out  of  it, 
lies  flattened  against  the  spine,  unless  old  and  firm  adhesions  resist  the 
compressing  forces.  If  there  be  much  fluid,  that  side  of  the  thorax 
will  be  enlarged,  the  intercostal  spaces  prominent,  the  diaphragm  de- 
pressed, the  heart  pushed  aside,  etc.  In  some  rare  instances  adhesions 
form  in  a  circle  between  the  two  pleural  surfaces,  making  a  central 
cavity  in  which  gas  and  fluid  will  accumulate  to  a  large  extent,  a  fistu- 
lous communication  having  been  established  with  a  bronchus. 

Symptoms. — Pneumothorax  is  to  be  studied  in  connection  with  the 
31 


322 


DISEASES   OF   THE   RESPIRATORY   ORGANS. 


diseases  from  which  it  arises.  It  may  develop  insidiously,  so  that  it  is 
discovered  only  on  making  physical  examination  of  the  chest.  Bnt, 
when  a  perforation  occurs  suddenly,  pronounced,  even  formidable, 
symptoms  are  at  once  produced.  Perforation  may  be  announced  by 
a  condition  almost  of  collapse,  a  temperature  of  97°  Fahr.,  and  a  small, 
weak,  but  very  rapid  pulse.  If  the  temperature  does  not  descend  so 
low,  the  pulse  is  weak  and  rapid,  and  the  resjjirations  are  hurried — the 
former  reaching  so  high  as  140,  the  latter  up  to  40,  even  60.  At  the 
same  time  dyspnoea  sets  in  with  orthopnoea,  and  a  severe  pain,  due 
either  to  sudden  stretching  of  the  pleura  or  tearing  apart  of  adhesions. 
In  other  cases,  for  example  phthisical  subjects,  none  of  these  severe 
symptoms  are  produced,  probably  because  narrowing  of  the  respiratory 
field  has  been  going  on  so  long  as  to  prej)are  them  for  this  additional 
discomfort.  The  decubitus  varies,  the  largest  number  seeking  a  posi- 
tion on  the  diseased  side  to  permit  the  freest  possible  play  of  the 
healthy  lung  ;  but  a  considerable  proportion  lie  upon  either  side,  al- 
though, when  air  first  entered  the  cavity,  orthopnoea  Avas  experienced  by 


Fig.  23. — Hydropneumothorax. 


most  of  the  cases.  The  dyspnoea  is  due  to  several  causes — to  sudden 
compression  of  the  lungs  and  the  heart,  and  to  a  compensatory  conges- 
tion, often  with  oedema  of  the  other  lung,  whence  the  expiratory  force 
is  lessened   and  the  voice  weak  and  trembling.     Cyanosis  appears  if 


PNEUMOTHORAX.  -  323 

there  is  mucli  difficulty  of  breathing,  the  surface  becomes  cold  and 
covered  with  a  cold  sweat,  the  tongue  is  blue  and  cold,  and  death  soon 
closes  the  scene  ;  or,  if  life  continues,  general  oedema  supervenes  from 
the  venous  stasis,  while  the  arterial  tension  is  low  from  ischsemia  of  the 
arteries.  The  lessening  of  the  expiratory  force  makes  the  cough  weak 
and  ineffectual,  and  the  expectoration  diminishes.  The  low  state  of 
the  arterial  tension  affects  the  urinary  secretion,  which  is  dense  and 
red,  with  traces  of  albumen.  The  vocal  fremitus  may  be  present,  di- 
minished, or  absent,  in  pneumothorax — present  when  there  are  strong 
bands  of  adhesion  which  communicate  the  vibrations  to  the  chest- 
walls  ;  diminished  when  the  lung  is  not  entirely  collapsed  ;  absent 
when  the  cavity  is  distended  with  gas.  On  palpation,  also,  increased 
resistance  will  be  noted  while  there  is  fluid,  and  increased  tension  with 
diminished  resistance  where  there  is  gas.  The  percussion-note  is  char- 
acterized by  its  marked  tympanitic  quality,  resonance,  and  elasticity. 
The  resonance  is  not  limited  to  the  part  containing  air,  but  extends 
downward  to  the  lower  margin  of  the  ribs,  extinguishing  the  hepatic 
dullness  in  its  usual  limits,  and  the  semi-lunar  space  on  the  left  side,  and 
also  extends  across  to  the  middle  of  the  sternum.  A  peculiar  metallic 
echo  may  be  developed  on  strong  percussion.  Percussion  over  the 
fluid  produces  the  usual  dull  sound  which  sharply  contrasts  with  the 
metallic  clang  of  the  percussion  over  air,  and  the  dullness  here  varies 
with  the  position  of  the  patient  and  follows  the  gravitation  of  the 
liquid.  The  character  of  the  percussion-note  is  affected  by  several  cir- 
cumstances :  when  thick,  false  membrane  lines  the  thoracic  wall  it 
acts  as  a  damper,  and  there  is  much  less  of  the  tympanitic  and  metallic 
quality  ;  when  an  external  oj^ening  exists,  there  will  be  produced  the 
cracked-pot  sound.  On  auscultation,  there  is  no  respiratory  sound,  ex- 
cept a  modified,  amphoric,  blowing  sound.  All  of  the  sounds  audible 
in  the  chest — cough,  rales,  heart-beat,  etc. — take  on  a  distinct  metallic 
quality.  The  dropping  of  fluid,  or  coughing,  or  movements  of  the 
body,  produce  under  these  circumstances  metallic  tinMing.  But  the 
most  characteristic  of  the  physical  signs  is  succussion — a  splashing  of 
the  liquid  against  the  walls  of  the  chest,  produced  by  a  sudden  shake 
of  the  body.  It  is  best  heard  by  applying  the  ear  to  the  chest,  and 
then  suddenly  shaking  the  body  by  the  hand  placed  on  the  patient's 
shoulder.  The  patient  often  recognizes  this  sound,  and  soon  learns  the 
best  movement  to  produce  it.  It  is  like  the  splashing  of  liquid  in  a 
half-empty  barrel. 

Course,  Duration,  and  Termination. — The  course  of  pneumothorax 
is  much  influenced  by  the  associated  lesions  and  the  extent  of  the  pul- 
monary insufiiciency.  If,  alreadj'',  the  respiratory  field  is  much  nar- 
rowed, death  may  ensue  in  a  few  hours  or  days.  Death  is  more  fre- 
quently produced  by  the  secondary  pleuritis  and  its  products,  causing 
slow  failure  of  respiration  after  some  weeks.     A  cure  is  not  to  be  ex- 


324    .  DISEASES   OF   THE   RESPIRATORY  ORGANS. 

pected  in  cases,  the  most  numerous,  due  to  perforation  of  a  superficially 
placed  cavity.  Pneumothorax  resulting  from  an  incised  wound  in  a 
healthy  subject  may  get  well  after  some  weeks.  A  perforation  occur- 
ring in  the  first  stage  of  phthisis  is  not  so  important  as  one  occurring 
later,  and  a  cure  is  possible  in  the  former  before  the  constitutional 
forces  are  much  depressed  by  the  progress  of  the  phthisis.  A  pneumo- 
thorax, produced  by  the  discharge  of  a  purulent  pleuritis  by  a  bronchus 
may  get  well  after  some  months.  It  may  be  stated  in  general  that  the 
prognosis  of  pneumothorax  is  unfavorable,  since  very  few  cases  get 
well  even  in  the  modified  way  of  a  permanent  fistula. 

Diagnosis.  —  Pneumohydrothorax  may  be  confounded  with  the 
large  caverns  of  phthisis,  with  dilated  bronchi,  with  emphysema, 
with  pleuritis  having  limited  effusion.  Vomicae  are  confined  to  the 
upper  part  of  the  lung,  have  formed  slowly  without  any  sudden  symp- 
toms ;  they  present  amphoric  sounds  and  metallic  tinkling,  rarely  suc- 
cussion  ;  vocal  fremitus  is  not  lessened  ;  the  chest-walls  are  retracted 
instead  of  distended,  and  the  heart  is  not  displaced.  In  pneumo- 
hydrothorax, loud,  deep,  tympanitic  percussion-note  is  obtained  all 
over  the  affected  side  ;  the  symptoms  have  occurred  suddenly,  and 
consist  of  severe  pain,  dyspnoea,  and  orthopncea  ;  well-marked  suc- 
cussion  ;  vocal  fremitus  lessened  or  absent ;  the  intercostal  spaces 
bulging  instead  of  retracted  ;  heart  and  other  organs  displaced.  Em- 
physema is  bilateral ;  the  respiratory  murmur  not  absent ;  bronchial 
rales  audible  all  over  the  chest  ;  vocal  fremitus  present.  Pneumo- 
hydrothorax is  unilateral ;  the  respiratory  murmur  entirely  absent, 
and  all  voice  and  breath  sounds  and  rales  from  the  affected  side  want- 
ing when  the  lung  is  collaj)sed  ;  vocal  fremitus  absent.  In  pleuritis, 
with  effusion,  the  percussion-note  has  a  tympanitic  quality  in  the 
infra-clavicular  region  ;  the  dullness  on  percussion  changes  with  the 
positions  of  the  patient,  and  corresponds  to  the  height  of  the  liquid; 
an  amphoric  murmur  is  exceptionally  audible  over  the  root  of  the  lung 
and  at  the  summit ;  with  the  increase  of  the  distention  of  the  chest, 
there  is  absolute  dullness  over  the  whole  side  ;  no  metallic  tinkling,  no 
succussion.  In  pneumohydrothorax,  the  percussion-note  has  a  loud, 
ringing,  tympanitic  quality  all  over  the  chest,  instead  of  a  modified 
normal  at  the  infra-clavicular  region,  and  this  tympanitic  note  is  not 
supplanted  by  absolute  dullness  ;  there  are  metallic  tinkling  and  suc- 
cussion in  perfection. 

Treatment. — As  respects  the  condition  associated  with  pneumo- 
thorax and  pneumohydrothorax,  the  treatment  is  indicated  under  the 
head  of  these  maladies,  and  need  not  now  be  discussed.  If  there  are 
much  dyspnoea  and  danger  of  acute  asphyxia,  no  time  should  be  lost 
in  making  a  free  opening  to  permit  the  exit  of  air.  The  pyopneumo- 
thorax is  to  be  treated  by  incision  and  the  drainage-tube,  and  the  use 
of  antiseptic  injections,  of  which  iodine  appears  to  the  author  to  be 


PNEUMONIA.  325 

the  best.  The  severe  pain  requires  the  use  of  anodynes,  unless  the 
free  exit  of  air  procured  by  incision  relieves  the  distress.  The  con- 
gestion and  oedema  of  the  sound  lung  may  be  relieved  by  ligatures 
to  the  thighs,  by  which  a  considerable  quantity  of  venous  blood  can 
be  retained  in  the  lower  limbs  long  enough  to  bridge  over  the  period 
of  danger.  This  expedient  is  preferable  to  bloodletting,  which  has 
been  recommended  for  this  purpose. 


PNEUMONIA— PNEUMONITIS— INFLAMMATION   OP   THE    LUNG. 

Definition. — Pneumonia,  an  acute  inflammation  involving  the  alveoli 
of  the  lungs,  is  designated  by  the  German  writers  "  croupous  pneumo- 
nia," and  by  the  French  writers  "  fibrinous  pneumonia."  "  Catarrhal 
pneumonia"  differs  from  the  fibrinous  or  croupous  form  in  the  seat 
and  character  of  the  inflammation.  It  attacks  the  capillary  tubes  im- 
mediately next  the  alveoli,  and  is  a  catarrhal  instead  of  a  croupous 
inflammation.  The  so-called  lobular  pneumonia  is  nothing  more  than 
catarrhal  pneumonia,  the  changes  in  the  lobules  being  secondary  to 
the  catarrhal  process  in  the  ultimate  bronchi.  Lobar  pneumonia  is  a 
fibrinous  or  croupous  pneumonia  occupying  and  confined  to  a  lobe. 
Pneumonia  is  also  known  in  common  language  as  "  lung-fever,"  "  win- 
ter-fever," etc. 

Causes. — There  is  a  growing  belief  that  pneumonia  is  a  constitu- 
tional disease,  like  typhoid  or  relapsing  fever.  It  differs  from  other 
inflammations  in  that  it  is  self -limited,  and  terminates  by  crisis.  It  is 
a  very  common  disease  ;  it  occurs  in  all  degrees  of  latitude,  under 
every  variety  of  climate,  and  at  all  ages.  It  is  common  in  infants  at 
the  breast,  but  declines  somewhat  after  the  second  year  until  after  the 
second  dentition,  and  is  frequently  encountered  and  is  very  fatal  in 
the  old.  The  masculine  sex  is  most  frequently  attacked,  because  men 
are  more  exposed  than  women  to  those  external  conditions  which  tend 
to  produce  it.  In-door  life,  a  vitiated  atmosphere,  excesses,  especially 
alcoholic,  and  bad  hygienic  influences  of  every  kind  which  induce  de- 
bility, favor  attacks  of  pneumonia.  Certain  seasons  appear  to  invite 
the  disease — those  parts  of  the  year  characterized  by  humidity  and  by 
variability  of  temperature.  In  the  British  Islands  winter  is  the  season 
of  greatest  prevalence  ;  on  the  Continent,  spring  ;  in  this  country, 
winter  and  spring,  the  former  especially — hence  the  name  winter-fever. 
Occasionally,  pneumonia  occurs  in  so  many  persons  in  a  particular 
district  that  it  may  seem  to  be  epidemic,  but  there  are,  probably,  sub- 
tile atmospherical  influences  at  work  to  produce  the  disease,  which 
elude  our  means  of  observation.  It  is  a  common  belief  that  pneumo- 
nia is  caused  by  exposure  to  cold,  especially  to  draughts  Avhen  the 
body  is  warm  and  perspiring.  That  catarrhal  pneumonia  is  induced 
in  that  way  no  one  will  dispute,  but  it  is  more  than  doubtful  that 


326  DISEASES    OF   THE   KESPIRATORY   ORGANS. 

croupous  pneumonia  is  thus  caused,  unless  there  exist  a  predisposition 
to  it,  either  of  a  vulnerable  constitution  or  an  inherited  tendency  to 
pulmonary  disease.  A  phthisical  tendency,  the  author  believes,  is  the 
chief  factor,  or  that  peculiarity  in  the  structure  of  the  pulmonary  tis- 
sue associated  with  consumption.  There  are  other  diathetic  states 
concerned  in  the  production  of  pneumonia — as  gout,  rheumatism,  dia- 
betes, the  eruptive  fevers,  especially  chronic  alcoholism. 

Pathological  Anatomy. — The  state  of  the  affected  lung  in  pneumo- 
nia is  usually  divided  into  three  stages,  following  the  orignal  descrip- 
tion of  Laennec,  based  on  the  naked-eye  appearances  :  engorgement; 
red  hepatization  ;  gray  hepitization.  The  better  arrangement,  based 
on  the  description  of  Jaccoud,*  but  modified,  is  as  follows  :  The  stage 
of  liypercBmia,  or  engorgement  ;  the  stage  of  exudation  (red  hepatiza- 
tion) ;  the  stage  of  resolution  (degeneration  and  extrusion  of  the  exu- 
dation) ;  the  stage  of  purulent  transformation  (gray  hepatization).  In 
the  stage  of  hypersemia  or  engorgement,  as  now  described,  there  are 
two  distinct  and  separate  acts — the  increased  blood-supply  and  the 
pouring  out  of  an  exudation.  The  lung  has  a  reddish-brown  appear- 
ance, is  heavier,  floats  in  water,  but  sinks  lower  than  the  normal  lung- 
tissue,  crepitates  but  little  when  pressed,  and  it  is  no  longer  elastic,  but 
when  an  impression  is  made  by  the  fingers  it  is  retained.  On  section 
it  presents  a  pretty  uniform  brownish-red  tint,  and  it  exudes  a  quantity 
of  blood.  On  microscopic  examination  the  blood-vessels  are  found  to 
be  distended  with  blood,  and  the  capillary  network  surrounding  the 
alveoli  is  so  much  enlarged  that  the  alveoli  are  encroached  on  by 
it.  f  The  adjacent  portions  of  the  bronchioles  are  similarly  en- 
gorged, the  mucous  membrane  dark  reddish  from  fullness  of  the  ves- 
sels. This  hypersemia  marks  the  first  stage  in  the  inflammatory  pro- 
cess. The  next  step  consists  in  the  pouring  out  and  coagulation  of 
an  exudation.  There  is  exuded  into  the  alveoli  an  albuminous  or 
fibrinous  fluid  of  great  viscidity,  and  with  it  leucocytes  which  have 
wandered  from  the  vessels,  and  red-blood  globules  present  by  diape- 
desis,  and  blood  by  the  rupture  of  distended  capillaries.  This  viscid 
albuminous  fluid  is  poured  out  also  into  the  bronchioles  and  bronchi  of 
the  inflamed  section,  and  with  it  leucocytes  and  some  red  coi'puscles. 
When  the  surfaces  approximate,  this  adhesive  fluid  holds  them  tightly 
together  until  the  incoming  air  separates  them.  In  the  capillaries  of 
the  inflamed  area  the  blood-current  is  finally  stopped,  and  the  corpus- 
cles are  then  seen  to  be  closely  packed  together  and  flattened  at  the 
points  of  contact.  The  albuminous  or  fluid  exudation  remains  fluid 
for  a  short  time,  and  then  solidifies  or  coagulates,  beginning  in  the 
alveoli  and  extending  through  the  bronchioles  outwardly.  In  coagu- 
lating it  incloses  the  white  and  red  corpuscles,  and  fills  out  the  alveolus 

*  "  Traite  de  Pathologie  "  ;  "  Interne,"  vol.  ii,  p.  45. 
\  Rindfleiscb,  op.  cit. 


PNEUMONIA.  327 

or  bronchiole,  probably  expanding  somewhat  in  the  act  of  coagulation. 
When  this  process  is  completed,  the  inflamed  part  is  solid,  entirely 
without  air,  and  falls  immediately  to  the  bottom  when  placed  in  a  ves- 
sel of  water  ;  it  is  also  friable,  is  easily  broken  up  between  the  fingers, 
but  on  section  with  the  knife  divides  cleanly  with  well-defined  mar- 
gins. The  cut  surface  pi-esents  a  reddish  color,  and  is  granulated  ; 
this  granular  appearance  being  due  to  the  little  masses  of  coagulated 
exudation  filling  the  cavity  of  the  alveoli.  These  little  masses  may 
with  some  care  be  lifted  out  of  the  mold  in  which  they  are  formed  and 
held  on  the  point  of  a  pin.  The  tissue  of  the  inflamed  part,  in  respect 
to  color,  density,  and  granular  appearance,  so  strongly  resembles  the 
cut  surface  of  a  section  of  the  liver  as  to  be  called  by  Laennec  red 
hepatization. 

There  are  two  directions  which  the  inflammatory  process  may  now 
assume  :  toward  resolution,  or  return  to  the  normal  state  ;  toward 
purulent  transformation.  As  the  first  is  the  more  usual,  we  describe 
first  the  process  of  resolution.  The  albuminous  material  which  had 
solidified  undergoes  liquefaction,  and  the  pressure  is  thus  removed 
from  the  surrounding  vessels.  The  watery  parts  of  the  exudation  dif- 
fuse into  the  vessels,  and  the  solids,  together  with  the  cellular  ele- 
ments, undergo  a  fatty  degeneration,  and  are  transformed  into  an 
emulsioned  mixture  without  any  of  the  viscidity  of  the  original  exu- 
dation, and  capable  either  of  absorption  or  of  extrusion,  much  of  it, 
doubtless,  being  expectorated.  As  the  exudation  liquefies,  air  again 
enters  the  alveoli,  diffusion  of  oxygen  into  and  of  carbonic  acid  out 
of  the  blood  is  resumed,  and  the  current  of  the  circulation  is  fully 
reestablished.  The  effusion  into  the  connective  tissue  between  the 
alveoli  and  bronchioles  is  finally  taken  up,  and  the  normal  color  and 
density  are  restored  to  the  inflamed  part,  but  its  elasticity  continues 
impaired  for  a  long  time. 

"When  the  purulent  transformation  takes  place,  a  change  is  wrought 
in  the  density,  color,  and  constitution  of  the  inflamed  area.  It  has 
been  much  discussed  whether  the  epithelium  of  the  alveoli  undergoes 
any  change,  and  contributes,  by  multiplication  of  its  cells,  to  the  exu- 
dation in  croupous  pneumonia,  and  whether  any  of  the  pus-corpuscles 
which  become  so  abundant  during  the  stage  of  gray  hepatization  or 
purulent  transformation  originate  by  proliferation  of  the  epithelial 
cells.  The  former  is  denied  by  most  authorities  ;  the  latter  is  highly 
probable  ;  but  the  pus-cells  are  derived  chiefly  from  the  wandering 
white  cells  by  multiplication  and  division.  With  the  formation  of 
pus-cells  a  process  of  fatty  degeneration  takes  place  in  the  albuminous 
exudation,  but  the  rapid  and  exuberant  formation  of  pus-cells  is  the 
principal  event,  the  tissue  being  changed  in  color  from  the  reddish- 
brown  appearance  of  the  red  hepatization  to  the  yellowish  or  grayish- 
yellow  tint  of  gray  hepatization.     When  such  tissue  is  squeezed  a 


328  DISEASES   OF   THE   RESPIRATORY   ORGANS. 

little,  a  quantity  of  pus  exudes,  and  the  whole  is  easily  broken  up  into 
a  fatty  and  granular  mass.  Not  all  parts  of  the  inflamed  area  are 
equally  advanced  in  suppuration,  some  parts  still  preserving  the  red- 
dish-brown, with  here  and  there  a  patch  of  yellow  ;  and  others  uni- 
formly grayish-yellow,  and  some  still  advanced  beyond  this  into  a 
yellowish,  almost  diffluent  mass.  The  stroma  of  the  lungs  yet  remains 
intact,  notwithstanding  the  enormous  production  of  pus-cells.  In  rare 
cases  a  portion  of  the  affected  tissue  proceeds  beyond  the  stage  of 
gray  hepatization,  or  purulent  transformation  ;  the  stroma  of  -the 
lungs  yields,  becomes  disintegrated,  and  a  small  purulent  collection 
is  formed.  A  large  abscess  may  be  formed  by  the  coalescence  of 
several  smaller  ones.  The  collection  may  be  bounded  only  by  disin- 
tegrating lung-tissue,  or  the  pus  may  be  inclosed  by  a  limiting  mem- 
brane, or,  in  other  words,  become  encysted.  The  author  has  seen  a 
case  of  encysted  abscess  occupying  a  part  of  the  middle  of  the  right 
lung,  which  had  existed  for  several  months  without  symptoms.  They 
may  discharge  by  a  bronchus,  or  into  the  pleura,  or  the  pus  of  the 
encysted  abscess  may  gradually  undergo  absorption.  The  termina- 
tion by  gangrene  is  much  more  uncommon  than  that  by  abscess,  and, 
when  it  does  occur,  signifles  a  most  depi'aved  state  of  the  tissues.  The 
passage  of  acute  into  chronic  pneumonia  is  a  comparatively  frequent 
occurrence,  when  the  disease  is  of  diathetic  origin,  especially  in  stru- 
mous subjects,  or  when  a  tendency  to  pulmonary  disease  exists. 
When  the  change  to  the  chronic  form  takes  place,  the  process  of  retro- 
grade metamorphosis  of  the  exudation  preparatory  to  its  extrusion  is 
arrested  ;  the  tissue  appears  comj^act,  grayish,  with  here  and  there 
dark  patches  of  j^igment  ;  the  hypergemia  has  ceased,  and  the  infil- 
trated liquid  is  absorbed.  In  other  cases  the  whole  of  the  inflamed 
area  does  not  pass  over  to  the  chronic  stage  ;  resolution  takes  place 
more  or  less  perfectly  ;  the  exudation  is  disposed  of  in  part,  but  still 
portions  remain,  more  or  less  impairing  the  functions  of  the  part.  In 
other  cases  the  products  of  inflammation  are  transfonned  into  caseous 
matter.  This  change  occurs  when  purulent  transformation  has  taken 
place.  The  pus  loses  the  fluid  in  which  the  corpuscles  float,  and  these 
bodies  become  fatty,  and  more  or  less  calcareous  matter  is  mixed  up 
^dth  the  fat,  the  ultimate  product  being  a  soft  solid,  looking  like  and 
having  the  consistence  of  cheese — whence  the  term  caseous  matter. 
It  must  be  stated  that  this  termination  to  croupous  pneumonia  is  re- 
garded by  the  best  modern  authorities  as  very  uncommon,  while  it  is 
usual  to  catarrhal  pneumonia.  All  parts  of  the  lung  are  not  equally 
susceptible  to  the  pneumonic  inflammation.  The  statistics  show  that 
the  right  lung  is  affected  alone  in  one  half  of  the  cases,  and  as  regards 
the  left  nearly  twice  as  often,  or,  to  express  the  relation  more  defi- 
nitely, using  the  statistics  of  Juergensen — the  right  lung  was  affected 
in  53*7  per  cent.,  the  left  lung  in  38-23  per  cent.,  both  lungs  in  8'07 


PNEUMONIA.  329 

per  cent.  The  inferior  lobe  of  the  right  lung  is  the  point  of  election, 
being  the  seat  of  inflammation  in  three  fourths  of  the  cases.  There 
are  certain  consequences  which  follow  on  a  pneumonia  that  ought  not 
to  be  overlooked.  When  a  considerable  part  of  a  lung  suddenly 
ceases  to  functionate,  there  must  be  disturbances  set  up  in  its  fellow. 
The  obstruction  to  the  pulmonary  circulation  induces  over-distention 
of  the  right  cavities  and  the  veins,  and  ischaemia  of  the  arteries.  The 
blood  displaced  from  the  inflamed  part,  and  which  can  not  circulate 
through  it,  induces  hyperaemia  and  cederaa  of  the  other  lung. 

Symptoms. — There  are  two  modes  of  onset  :  in  the  less  frequent 
there  has  been  a  day  or  two  of  bronchial  catarrh  and  general  malaise, 
when  some  chilliness  is  experienced,  pain  is  felt  in  the  side,  and  the 
disease  proceeds  in  its  usual  way.  In  the  other  and  more  frequent 
mode,  a  decided  rigor  is  the*  initial  symptom — a  rigor  more  severe 
than  in  any  diseases  except  malarial  fever  and  pyaemia.  Elevation  of 
temperature  occurs  at  once,  and  by  the  evening  of  the  first  day  has 
reached  about  104°  Fahr.  In  infants,  instead  of  chill  there  may  be 
a  violent  general  convulsion  or  several  of  them.  The  duration  of  the 
cold  stage  is  from  a  quarter  of  an  hour  to  three  or  four  hours,  and  dur- 
ing it  the  thermometer  in  the  axilla  notes  some  slight  elevation  of 
temperature,  and  in  a  few  hours  not  only  is  the  external  temperature 
high,  but  the  subjective  sense  of  heat  is  great.  The  face  is  flushed, 
the  eyes  injected,  there  are  intense  headache,  severe  pains  in  the  back, 
and  muscular  soreness  in  the  members.  The  pulse  is  large  in  volume 
and  strong  in  tension.  There  is  usually  a  whitish-coated  tongue,  the 
appetite  is  wanting,  and  the  stomach  is  nauseated,  or  there  are  attacks 
of  A'omiting  on  the  first  day.  By  the  end  of  the  first  day,  or  the  be- 
ginning of  the  second,  there  are  rational  symptoms  which  indicate  the 
chest  as  the  seat  of  the  mischief.  Pain  in  the  side  is  experienced,  and 
difliculty  of  breathing  and  cough  now  come  on.  The  pain  in  the  side 
varies  in  severity,  and  indeed  is  not  always  present.  If  the  pleura  is 
involved,  the  pain  is  more  prompt  and  more  acute  ;  if  the  deepest  part 
of  the  lung,  there  may  be  no  pain  until  the  inflammation  approaches 
the  surface.  The  pain  is  most  severe  when  it  is  first  felt,  and  then  it 
usually  declines.  The  position  of  the  pain  is,  as  a  rule,  in  the  right 
chest,  a  little  below  and  external  to  the  nipple,  but  it  may  be  felt  in 
the  lumbar  region,  in  the  iliac  region,  and  in  the  shoulder.  When 
pneumonia  has  attacked  the  summit  of  the  lung,  or  as  it  occurs  in  the 
aged,  pain  may  be  absent.  Coughing,  breathing,  especially  a  deep  ex- 
piration, increase  the  pain.  Accompanying  the  pain,  or  coming  soon 
after  it,  is  dyspnoea  ;  the  respiratory  acts  are  more  frequent  and  shal- 
low, reaching  as  high  as  thirty  or  forty  per  minute,  the  shallowness  being 
due  to  the  pain  caused  by  full  breathing,  and  by  the  narrowing  of  the 
respiratory  field.  The  flushed,  anxious,  and  somewhat  dusky  counte- 
nance, the  working  of  muscles  of  respiration  merely  accessory,  and 


330 


DISEASES   or   THE   EESPIEATORY   ORGANS. 


those  of  the  alse  of  the  nose,  make  up  an  expression  which  has  been 
called  fades  pneumonica.  The  cough,  which  appears  on  the  first  or 
second  day,  is  very  characteristic  ;  it  is  husky,  suppressed,  and  painful. 
At  first  there  is  brought  up  a  little  frothy  mucus,  but  on  the  third 
day  there  appear  the  sputa  characteristic  of  this  disease  ;  thick,  viscid 
material  like  that  which  is  poured  out  and  coagulates  in  the  alveoli 
and  bronchioles  of  the  lung.  The  sputum  also  contains  blood-corpus- 
cles intimately  incorporated  with  the  viscid  albuminous  matter,  but 
in  varying  proportion  of  coloring,  from  a  light  brick-red  to  a  brownish- 
black.  So  tenacious  and  adhesive  is  the  sputum  that  it  remains  adher- 
ent to  the  bottom  of  the  vessel  if  turned  over,  and  if  a  considerable 
quantity  is  collected  in  a  vessel  it  presents  a  jelly-like  appearance  of  con- 
sistency. The  blood  is  not  always  mixed  with  the  sputa  at  first,  but 
the  peculiar  characteristics  of  the  expectoration  are  in  other  respects 
present,  the  blood  appearing  in  four  or  five  days.  In  some  debilitated 
subjects — for  example,  the  subjects  of  chronic  alcoholism — the  expec- 
toration is  thinner  and  more  abundant,  presenting  an  appearance  like 
prune-juice,  whence  the  name  prune-jidce  expectoration — an  ill-omen. 
Again,  there  may  be  no  exjjectoration  at  all,  which  is  sometimes  the 
case  in  very  adynamic  states,  and  in  pneumonia  of  the  apex.  There 
are  also  present  in  the  sputa  casts  of  the  finer  bronchi.  The  sputa 
should  be  agitated  with  water,  and  the  grayish,  undissolved  particles 
should  be  fished  out  and  then  be  f)ut  under  the  microscope.     They  are 

■^  fibrous  in  structure,  cylindrical,  and 
branching.  As  has  been  stated,  the 
maximum  temperature  is  soon  at- 
tained. On  the  evening  of  the  first 
day  it  may  reach  104°  Fahr.  (axil- 
lary), and  for  several  days  it  con- 
tinues at  about  103°,  104°,  or  even 
105°,  there  being  a  slight  morning 
remission  and  evening  exacerbation. 
The  fever  pursues  this  course  with 
little  variation  in  favorable  cases, 
imtil  the  period  of  crisis,  when  just 
before  the  defervescence  a  rise  may 
take  place.  This  rise  in  temperature 
in  anticipation  of  the  crisis  is  usual 
"but  by  no  means  invariable.  The  pulse  during  the  stage  of  hyperse- 
mia  is  about  100— full,  hard,  and  strong  ;  but,  as  consolidation  takes 
place,  if  extensive  or  extending  widely,  a  change  occurs  in  the  pulse  ; 
it  becomes  less  full,  and,  when  the  ischemia  of  the  arterial  side  has 
reached  the  lowest  point,  the  pulse  is  small,  soft,  and  weak,  and  the 
superficial  veins  are  abnormally  full  and  prominent.  The  skin,  during 
the  time  of  greatest  fever,  is  mordicant,  or  burning-hot,  and  is  dry  or 


Fig.  24. — Fibrous  Tissue  in  Sputa.    (Beale.) 


PNEUMONIA.  33 1 

covered  with  a  warm  perspiration.     If  the  skin  is  relaxed,  dusky,  cool, 
and  covered  with  a  cold  sweat,  the  condition  is  unfavorable. 

If  the  inflamed  area  is  deeply  situated  and  surrounded  by  healthy 
lung-tissue,  the  reactions  produced  on  palpation  and  percussion  are 
modified.  On  palpation  the  resistance  is  increased  if  the  inflamed 
lung  is  exterior  ;  not  affected,  if  within.  The  vocal  fremitus  is  some- 
what increased.  The  sonority  is  diminished  when  the  lung  is  con- 
solidated ;  it  is  exaggerated  when  there  is  a  layer  of  lung-tissue  con- 
taining air  overlying  a  consolidated  area.  Again,  the  sonority  is 
exaggerated,  or  tympanitic,  when  in  the  beginning  of  the  inflammation 
the  lung  still  contains  some  air.  The  sound  continues  somewhat  tym- 
panitic in  quality  about  the  consolidated  portion  of  the  lung  at  the 
maximum.  With  the  progress  of  the  exudation,  and  when  the  periph- 
eral portion  of  the  lung  is  involved,  there  is  greatly  increased  resist- 
ance, and  the  percussion-note  over  the  inflamed  area  is  flat,  with  still 
something  of  the  tympanitic  quality.  The  vesicular  murmur  becomes 
more  and  more  feeble  as  the  air  less  and  less  distends  the  alveoli. 
AYithin  twenty-four  to  thirty-six  hours  there  is  heard,  with  or  at  the 
end  of  inspiration,  a  fine  crackling  sound  over  the  region  inflamed — 
the  crepitant  rale.  This  is  wrongly  said  to  be  pathognomonic,  since  it 
occurs  in  acute  tuberculosis,  oedema  of  the  lungs,  etc.  ;  but  it  is  highly 
significant  in  that  it  is  audible  in  so  few  conditions,  and  occurs  in 
pneumonia  over  a  restricted  area.  This  rale  has  been  compared  to  the 
sound  produced  by  rubbing  a  lock  of  hair  between  the  fingers  in  front 
of  the  ear,  to  the  burning  of  some  grains  of  salt  on  live  coals,  but  it  is 
most  perfectly  imitated  by  the  crackling  made  by  India-rubber  sponge 
when  pressed  and  allowed  to  expand  in  front  of  the  ear.  As  the  sound 
is  produced  by  the  separation  of  the  bronchioles  and  alveoli,  adherent 
by  the  viscidity  of  the  albuminous  exudation,  it  is  obvious  that  it  can 
occur  only  during  inspiration.  When  consolidation  takes  place,  the 
crepitant  rdle  ceases,  but  can  be  heard  in  the  neighboring  parts  of 
the  lung  undergoing  the  same  process.  Again,  it  becomes  audible 
when  the  stage  of  resolution  is  reached.  It  is  then  known  as  crepitatio 
redux,  but  it  then  differs  somewhat  in  quality,  and  is  coarser  and 
louder.  The  crepitant  rdle  in  children  and  old  subjects  is  much  like 
the  crepitation  redux.  This  rdle  is  audible  for  a  brief  period  only, 
during  the  stages  of  engorgement  and  exudation  ;  presently  the  vesic- 
ular murmur  ceases  altogether  ;  the  respiration  becomes  sibilant,  then 
blowing,  and  on  the  third  day  bronchial  breathing  and  bronchial  voice 
come  on.  The  conductivity  of  the  lung  being  increased  by  consolida- 
tion, the  sound  produced  by  the  vibration  of  a  column  of  air  in  the 
larger  bronchi  is  communicated  directly  to  the  ear — whence  the  term 
bronchial  breathing.  The  voice-sounds  are  communicated  with  equal 
distinctness  to  the  ear  from  the  larger  bronchi — whence  bronchial 
voice.     When  the  lung-tissue  is  consolidated,  the  disease  is  at  its  maxi- 


332  DISEASES   OF  THE   RESPIRATORY   ORGANS. 

mum  ;  there  may  be  an  extension  of  the  area  of  inflammation  in  all 
directions,  but  the  symptoms  continue  with  uniform  intensity  for  sev- 
eral days.  We  must  now  return  to  the  rational  symptoms  and  follow 
their  development  up  to  the  period  of  crisis.  The  fever  continues 
pretty  uniformly  at  the  point  already  mentioned,  102°,  103°,  104°,  or 
105° — there  being  a  morning  remission  of  less  than  a  degree.  The  pain 
in  the  side  lessens  or  ceases  altogether.  The  decubitus  is  toward  the 
right  with  the  body  flexed,  so  as  to  relax  the  muscles  of  the  affected 
side,  and  thus  take  the  pressure  off  ;  but  the  dyspnoea  is  less,  because, 
the  pain  having  declined,  the  respiration  is  free,  but  there  is  still 
some  difiiculty  in  respiration.  The  cough  is  more  or  less  troublesome, 
and  the  characteristic  rusty*  expectoration,  or  the  more  abundant 
"prune-juice,"  is  brought  up  with  every  effort.  Sometimes  the  ex- 
pectoration is  haemorrhagic,  and  several  ounces  may  be  discharged  at 
a  time.  The  smallness  of  the  pulse  and  feebleness  of  the  cardiac  im- 
pulsion are  due  to  ischsemia  of  the  arterial  side,  as  has  been  pointed 
out ;  on  the  other  hand,  this  state  of  the  circulation  may  be  largely 
due  to  depression  of  the  forces.  If  the  area  involved  in  the  inflamma- 
tion is  not  very  large,  the  pulse  may  continue  full  and  strong  up  to  the 
crisis  ;  if  this  area  is  large  and  extending,  then  the  fullness  of  the 
venous  system  and  the  emptiness  of  the  arterial  will  have  the  effect 
just  stated  over  the  circulatory  system  ;  consequently,  the  condition 
of  the  circulatory  system  will  afford  valuable  information  in  respect 
to  the  extent  of  lung-tissue  involved  in  inflammation.  A  rapid  and 
weak  pulse — 120,  130,  140 — irregularities  in  the  rhythm,  and  unequal 
filling  of  the  artery,  are  very  ugly  symptoms,  denoting  cardiac  failure. 
Delirium  is  a  result  of  the  diminished  arterial  supply  and  the  venous 
stasis  of  the  brain  ;  there  may  be  merely  hallucinations  or  illusions,  or 
noisy  and  violent  delirium.  Mental  disturbance  is  more  especially 
present  in  the  cases  of  pneumonia  occurring  in  drunkards  ;  delirium 
tremens  too  often  masks  so  completely  the  pulmonary  symptoms  that 
they  are  overlooked.  In  such  cases,  the  pneumonia  is  the  disease,  and 
the  delirium  tremens  the  symptom  or  complication,  instead  of  the 
reverse.  The  obstruction  at  the  lungs  and  the  consequent  venous 
stasis  affect  other  organs  besides  the  brain.  The  liver  is  congested, 
and  jaundice,  more  or  less  decided,  is  present  in  many  cases,  whence 
the  name  bilious  pneumonia.  Again,  the  pneumonia  of  malarious 
regions  is  so  often  modified  by  malarial  infection  that  the  biliary  dis- 
turbance may  be  either  caused  or  increased  by  this  influence.  Fur- 
thermore, an  accompanying  gastro-duodenal  catarrh  may,  by  an  exten- 
sion of  the  catarrhal  process  to  the  bile-ducts,  set  up  a  catarrhal  jaun- 
dice. All  of  these  influences  coinciding,  the  biliary  disturbance  may 
enter  largely  into  the  symptomatology  and  therapeutics  of  the  case. 
Very  rarely  a  case  of  pneumonia  may  be  complicated  by  acute  yellow 
atrophy.     The  urinary  secretion  is  altered  in  quantity  and  in  compo- 


TNEUMONIA. 


333 


sition  ;  the  quantity  is  reduced  ;  the  urea  and  uric  acid  are  increased, 
and  the  chlorides  are  much  diminished  or  disapjDear  entirely.  The 
chlorides  are  diverted  to  the  inflamed  pai't  and  from  the  urine,  so  that 
the  return  of  the  chlorides  (chloride  of  sodium  chiefly)  to  the  urine 
signifies  the  cessation  of  the  inflammation.  So  sensitive  is  this  indica- 
tion, that  the  return  of  the  chlorides  to  the  urine  may  precede  for 
some  hours  the  physical  and  rational  signs  which  indicate  the  begin- 
ning of  resolution.  In  consequence  of  the  venous  stasis,  the  hyper- 
semia  of  the  kidneys  may  induce  albuminuria,  and  the  urine  may  con- 
tain also  cast-off  epithelium  of  the  tubules,  but  the  albuminuria  is  a 
transient  state.  It  should  be  noted  also  that,  during  albuminuria, 
pneumonia  arises  as  a  complication,  and  not  unfrequently  a  fatal  one. 

Pneumonia  is  one  of  the  few  diseases  terminating  by  crisis.  The 
critical  phenomena  consist  in  a  sudden  decline  of  temperature  by  crisis 
or  lysis,  and  the  occurrence  of  some  sjDecial  evacuation,  as  a  large 
urinary  discharge,  a  profuse  diarrhoea,  general  sweating,  an  herpetic 


Day 

2     3 

4    5 

6     7     8 

9     10 

11     1 

2 

tor 

102° 
100° 
98° 
96° 

J 

J 

X^    ^ 

V^^l 

__vp^  _ 

,    Z^ 

« 

4 

5     ^     -i 

'v 

/  I 

«      / 

/  \ 

/  \ 

~X(v-L 

V 

v 

-M    tj- 

-V     -y 

Fig.  25.— Temperature  of  Uncomplicated  Pneumouia  of  Bight  Lung.    Termination  by  Crisis. 

eruption,  or  considerable  expectoration.  The  return  in  a  few  hours  to 
the  normal  temperature  or  below  it  is  the  most  conspicuous  of  these 
phenomena.  As  has  been  narrated,  just  before  the  defervescence,  the 
temperature  may  rise  higher  than  it  had  been,  and  the  aspect  of  the 
case  appear  more  formidable  ;  then  the  decline  begins,  and  within 
twelve  hours  the  normal  or  somewhat  below  it  be  reached,  or,  if  by 
lysis,  the  descent  to  normal  occupies  two  or  three  days.  The  change 
thus  wrought  in  the  aspect  of  the  patient  is  most  remarkable.  The 
countenance  clears  up,  the  difficulty  of  breathing  subsides,  the  pulse 
falls  to  seventy,  to  sixty,  even  to  forty  jser  minute,  and  an  herpetic 
eruption  appears  on  the  lips  ;  appetite  returns,  the  skin  is  covered  with 
warm  perspriation,  the  urine  increases  in  amount,  the  chlorides  reap- 
pear, and  the  patient  experiences  an  internal  sense  of  well-being.  The 
physical  are  in  accord  with  these  rational  signs  :  moist  sounds  now  ap- 
pear in  the  bronchical  tubes,  and  the  sputa  become  lighter  in  color,  and 


33J: 


DISEASES   OF   THE   RESPIRATORY   ORGANS. 


an  abundant  expectoration  of  grayish-yellow  muco-pus  takes  the  place 
of  the  rusty  sputa  ;  crepitatio  redux,  coarser  than  crepitatio  indux^  ap- 
pears along  the  outer  border  of  the  consolidated  area  ;  bronchophony 
is  succeeded  by  a  softer  blowing  sound  ;  the  flatness  is  now  dullness, 
with  more  of  the  tympanitic  quality,  and  the  vocal  fremitus  is  less 
decided.  Careful  examination  of  the  sputa  during  the  stage  of  resolu- 
tion will  disclose  the  presence  of  the  fibrinous  casts  of  the  finer  tubes, 
already  described,  and  small  masses,  remains  of  the  coagulated  exuda- 
tion in  the  air-sacs.  The  alveoli  are  gradually  opened  up  to  the  ad- 
mission of  air,  and  under  favorable  circumstances  the  restoration  of 
the  lung  is  complete  in  a  few  days.  In  some  unhealthy  subjects,  the 
victims  of  a  diathesis,  and  sometimes  those  whose  vital  forces  have 
been  reduced  by  depressing  treatment,  repair  is  incomplete,  and  the 
affected  part  lapses  into  the  chronic  state.  When  the  course  is  not 
toward  crisis  and  health,  there  may  be  abortive  attempts  at  crisis  ; 
there  may  be  some  considerable  subsidence  of  the  temperature,  an 
illusive  appearance  of  a  critical  evacuation  in  the  way  of  an  exhausting 
diarrhoea,  for  example,  but  the  natural  powers  are  not  equal  to  the 
effort ;  there  is  no  real  improvement,  the  temperature  rises  even  higher 


Day    4.     5    6     7     8     9 

fO    II    12   13    14  15 

lOS" 

106°                                 I 

'\ 

-vX 

-*2    X- 

t      \- 

'04      ^       i^       t       4 

I       115    _,       ZO 

zs     L  s^2 

. j     X'^ 

r 

\-J 

X    4 

102         ir 

-«=i?H 

_4\ 

I 

100° 

^ 

t 

J5 

\ 

98" 

^=^ 

L_                     _, 

t^   7- 

u            i^^ 

,96* 

Fig.  26. — Temperature  of  Uncomplicated  Pneumonia  terminating  by  Lysis. 

than  before,  and  all  of  the  symptoms  develop  new  severity.  The  pulse 
declines  in  strength  and  volume  and  becomes  very  frequent,  the  dysp- 
noea increases,  and  an  adynamic  state,  in  which  the  tongue  is  dry, 
the  face  cyanosed,  the  breathing  quick  and  shallow,  and  the  debility 
great,  supervenes.  If  delirium  had  existed  before,  it  now,  assumes 
more  of  the  low-muttering  character  ;  if  it  had  not  existed  before,  it 
is  now  apt  to  come  on  in  the  form  of  hallucinations  ;  there  are  increas- 


PNEU^MONIA.  335 

ing  somnolence  and  a  tendency  to  coma  as  the  venous  stasis  and  car- 
bonic-acid poisoning  increase,  and  finally  a  condition  of  more  or  less 
profound  coma  ushers  in  death. 

Complications. — Pleurisy  is  a  frequent  complication,  the  two  dis- 
eases occurring-  together  in  from  ten  to  twenty  per  cent.  A  more 
acute  pain  and  the  usual  signs  of  effusion  are  the  only  evidences  of 
the  existence  of  pleuro-pneumonia.  The  effusion  must  amount  to  six 
ounces  to  be  detected  with  certainty  (Juergensen).  If  there  be  exten- 
sive consolidation,  the  effusion  must  be  proportionally  small.  Pleuritis 
is  ascertainable  with  certainty  only  if  there  be  sufficient  effusion  to 
displace  the  heart.  The  existence  of  pleuritis  does  not  modify  the 
course  and  behavior  of  the  pneumonia  itself,  but  the  situation  is  ren- 
dered more  grave  by  the  simultaneous  development  of  the  two  dis- 
eases. Capillary  bronchitis  is  a  very  dangerous  complication  of  croup- 
ous pneumonia,  and  may  so  conceal  the  latter  as  to  appear  as  a  case  of 
catarrhal  pneumonia.  Emphysema  is  an  occasional  complication  ;  it 
should  be  stated,  however,  that  pneumonia  is  an  ordinary  mode  of  ter- 
mination of  emphysema.  Pericarditis  is  more  frequently  a  complica- 
tion of  pleuritis,  but  it  may  also  occur  in  the  course  of  pneumonia. 
Granular  degeneration  of  the  heart-muscle  occurs  in  pneumonia  when 
the  temperature  is  persistently  high,  and  is  a  serious  complication. 
The  occurrence  of  jaundice  has  been  alluded  to  as  a  symjjtom,  and  its 
mechanism  explained.  That  pneumonia  is  a  disease  of  great  frequency 
and  fatality  in  malarious  regions  is  undoubted.  Rheumatism  and  gout 
are  also  frequently  associated  with  pneumonia,  and  to  these  may  be 
added  acute  alcpholismus.  Pneumonia  of  diathetic  origin  is  severe  or 
not  according  to  the  character  of  the  diathesis  ;  it  is  very  fatal  in  the 
alcoholic,  but  not  more  so  than  the  uncomplicated  malady  in  the  rheu- 
matic or  gouty  form.  The  existence  of  a  typhoid ptieumonia  is  pretty 
generally  admitted,  but  on  questionable  evidence.  Pneumonia  is  an 
occasional  complication  of  typhoid  fever,  but  it  is  not  a  typhoid  pneu- 
monia. This  term  is  applied  to  a  form  of  pneumonia  occurring  in  the 
weak  and  debilitated,  and  has  therefore  a  specially  adynamic  character. 
There  is  not  the  fever  process  which  we  designate  typhoid ;  there 
exists  a  pneumonia  to  which  a  specially  adynamic  character  has  been 
imparted  by  the  depressed  state  of  the  vital  forces.  The  term  has 
been  so  far  generalized  that,  in  many  places,  every  severe  case  of 
pneumonia  is  called  typhoid  pneumonia. 

Course,  Duration,  and  Termination. — Croupous  pneiimonia  is  a  well- 
defined,  self-limited  disease,  which  passes  through  its  several  stages 
with  considerable  uniformity.  The  stage  of  congestion  or  engorge- 
ment occupies  the  first  twenty -four  to  thirty-six  hours  ;  the  stage  of 
exudation  or  red  hepatization — that  period  occupied  by  the  pouring  out 
and  coagulation  of  the  exudation — continues  up  to  the  crisis,  which 
marks  the  beginning  of   the  next  stage.     The  crisis  in   pneumonia 


336  DISEASES   or   THE   RESPIRATORY   ORGANS. 

occurs  somewhere  from  tlie  fifth  to  the  eleventh  day  of  the  disease,  so 
that  the  exudation  stage  lasts  from  two  to  eleven  days.  The  stage  of 
resolution  begins  with  the  phenomena  of  the  crisis,  and  lasts  two  to 
four  days  till  convalescence  is  established.  In  rare  cases  (abortive 
foi-ms)  critical  phenomena  may  occur  even  earlier  than  the  fifth  day. 
In  the  largest  number  the  crisis  begins  on  the  seventh  day,  and,  accord- 
ing to  Traube,  always  on  the  odd  days,  reckoning  from  the  day  of  the 
initial  chill,  but  if  we  except  the  seventh  day  the  statement  of  Traube 
must  be  denied.  The  stage  of  purulent  transformation  is  not  dis- 
tinctly separated  from  the  stage  of  exudation  or  red  hepatization, 
unless  the  occurrence  of  an  abortive  attempt  at  crisis  fixes  the  period. 
It  begins  about  the  middle  of  the  second  week,  and  continues  for 
several  days  to  a  week.  The  whole  course  of  pneumonia  is  therefore 
comprehended  within  three  weeks,  but  favorable  cases  may  terminate 
in  two  weeks.  The  mortality  from  pneumonia  has  been  and  continues 
to  be  a  subject  of  warm  discussion  on  the  j)art  of  those  who  advocate 
some  special  plan  of  treatment.  Accuracy  in  diagnosis  and  skill  in 
treatment  are  such  uncertain  elements  in  the  statistics  of  mortality, 
under  different  plans  of  treatment,  that  but  little  reliance  can  be 
placed  on  the  statistical  method  as  aj)plied  to  therapeutical  questions. 
According  to  the  most  approved  of  the  modern  methods,  the  mortality 
ranges  from  five  to  twenty-five  per  cent.  In  determining  a  fatal  re- 
sult in  croupous  pneumonia,  so  much  depends  on  the  condition  of  the 
individual  attacked,  or  the  diathesis  with  which  his  system  is  tinctured, 
that  no  comparison  of  systems  of  treatment  can  be  accurate  that  does 
not  take  note  of  them.  Death  is  usually  due  to  collapse — that  is,  cai-- 
diae  failure,  and  obtunding  of  the  nervous  centers.  This  state  is  not 
necessarily  caused  by  purulent  transformation — it  may  be  due  to  fail- 
ure of  heart,  and  lungs,  and  brain,  before  the  end  of  the  stage  of 
red  hepatization.  Death  may  be  caused  by  the  mere  extent  of  the 
lesions  in  the  lungs,  inducing  asphyxia  ;  these  lesions  consisting  not 
only  of  localized  pneumonia,  but  also  of  collateral  hypersemia  and 
cedema.  The  effects  of  the  pulmonary  changes  are  enhanced  by  the 
stasis  in  the  cerebral  veins  and  ischsemia  of  the  arteries,  and  by  car- 
diac paresis.  In  subjects  extremely  delibitated,  the  tissues  in  a  scor- 
butic state,  the  termination  may  be  by  gangrene,  but  this  is  extremely 
rare.  The  formation  of  an  abscess  is  also  rare,  but  is  more  common 
than  gangrene.  An  example  of  encysted  abscess  which  had  been 
carried  many  months  has  been  mentioned  ;  usually  the  abscess  formed 
during  the  stage  of  gray  hepatization  terminates  in  a  short  time  by 
discharge  either  into  the  pleural  cavity  or  into  a  bronchus.  The  pres- 
ence of  a  quantity  of  the  elastic  tissue  of  the  lungs  in  the  sputa  and  the 
occurrence  of  repeated  rigors  and  profuse  sweats  indicate  the  forma- 
tion  of  the  abscess.  If  it  become  encysted,  just  as  is  the  case  in  ab- 
scess in  the  liver  or  in  the  brain,  the  acute  symptoms  subside,  the  fever 


PNEUMONIA.  337 

falls,  the  rigors  and  sweats  cease,  but  yet  some  unfavorable  symptoms 
continue — there  are  cough,  fever,  dry  tongue,  emaciation,  and  weak- 
ness, and  the  appropriate  physical  signs.  In  a  variable  period  the 
abscess  terminates  in  some  of  the  modes  already  described.  The  ter- 
mination may  be  in  the  chronic  form.  There  are  then  no  critical 
phenomena  ;  the  fever  gradually  diminishes,  but  does  not  cease  ;  the 
difficulty  of  breathing  lessens,  but  there  is  more  or  less  embarrassment 
on  making  any  effort ;  the  cough  also  continues,  and  muco-pus  and 
fibrous  tissue  are  expectorated  ;  the  weakness  and  emaciation  do  not 
improve  if  the  decline  does  not  go  on,  and  the  physical  signs  of  con- 
densation of  the  pulmonary  tissue  remain.  The  subsequent  behavior 
is  influenced  by  the  local  condition  and  the  direction  taken  by  the 
products  of  inflammation.  There  may  ensue  a  gradual  liquefaction  of 
the  exudation,  its  softening  and  extrusion  may  be  effected  without 
much  damage  to  the  pulmonary  parenchyma,  and  after  some  months  a 
cure  be  effected.  On  the  other  hand,  the  exudation  may  undergo  casea- 
tion, with  the  usual  history  of  pulmonary  consumption.  The  caseation 
of  the  inflammatory  products  of  croupous  pneumonia  is  held  to  be 
doubtful  by  many,  and  is  not  regarded  as  common.  The  clinical  his- 
tory is  that  of  caseous  pneumonia,  and  need  not  be  discussed  until  that 
subject  is  reached.  Finally,  death  may  be  caused  by  one  of  the  com- 
plications, as  pericarditis. 

Diagnosis. — Ordinary  well-defined  cases  are  recognized  without 
difficulty  ;  it  is  the  obscure  or  anomalous  forms  that  occasion  mis- 
take. Pleurisy  with  effusion  is  very  frequently  confounded  with 
pneumonia.  They  are  differentiated  by  the  following  points  :  The 
onset  of  pneumonia  is  sudden,  by  a  rigor,  and  followed  by  a  high  tem- 
perature— pleurisy  begins  more  gradually,  there  is  chilliness  for  a  day 
or  two,  and  the  rise  of  temperature  is  gradual ;  in  pneumonia,  the  pain 
is  rather  dull,  or  a  feeling  of  soreness  diffused  over  a  considerable 
space — in  pleurisy,  a  sharp  stitch,  which  can  be  covered  by  a  finger ; 
in  pneumonia,  there  is  audible,  on  inspiration  only,  a  crackling  sound, 
the  crepitant  rale — in  pleurisy,  the  friction-sound,  synchronous  with 
the  respiratory  movements  ;  in  pneumonia,  the  crepitant  rdle  is  suc- 
ceeded by  bronchophony,  which  continues — in  pleurisy,  when  the  effu- 
sion partly  compresses  the  lung,  a  modified  bronchophony,  but,  when  the 
lung  collapses,  all  voice  and  breath  sounds  cease  ;  in  pneumonia,  the 
dullness  has  a  tympanitic  quality,  and  is  fixed  in  position — in  pleurisy, 
the  dullness  is  flat,  and  changes  with  the  gravitation  of  the  fluid  ;  in 
pneumonia,  the  organs  retain  their  position — in  pleurisy,  the  heart  is 
pushed  aside  and  the  liver  downward  by  the  effusion  ;  pneumonia  is 
self-limited,  and  terminates  by  crisis — these  phenomena  are  wanting 
in  pleurisy,  the  duration  of  which  is  indefinite  ;  subsequent  to  the 
crisis,  the  behavior  of  the  two  diseases  is  so  different  that  further 
comparison  is  unnecessary.  Next  to  pleuritis  with  effusion,  pneu- 
22 


338  DISEASES  OF  THE  RESPIRATORY  ORGANS. 

monia  is  confounded  with  catarrhal  pneumonia.  They  differ  in  onset 
— pneumonia  sudden,  with  a  rigor,  and  pain  in  the  side — catarrhal 
pneumonia  with  an  ordinary  bronchitis,  and  a  feeling  of  soreness 
rather  than  pain  under  the  sternum  ;  pneumonia,  as  a  rule,  is  unilat- 
eral, self -limited,  terminating  by  crisis,  or  ceasing  within  three  weeks 
— catarrhal  pneumonia  is  bilateral,  not  limited  nor  terminating  by 
crisis,  and  indefinite  in  duration  ;  if  double,  which  is  rare,  pneumonia 
is  limited  to  a  portion  of  either  lung,  while  catarrhal  pneumonia  is 
diffused  over  both.  The  differentiation  of  bronchitis  and  croupous 
pneumonia  rests  upon  the  same  points.  In  respect  to  physical  signs, 
the  differences  are  marked :  In  pneumonia,  the  vocal  fremitus  is  in- 
creased, and  there  is  increased  resistance  on  palpation — in  bronchitis, 
the  vocal  fremitus  is  unaffected,  and  there  is  no  change  in  the  resist- 
ance ;  in  pneumonia,  there  is  dullness  on  percussion — in  bronchitis, 
the  percussion-note  is  unaltered  ;  in  pneumonia,  on  auscultation,  there 
is  audible  the  crepitant  rale,  which  disappears  and  is  replaced  by  bron- 
chophony— in  bronchitis,  there  is  no  crepitant  but  a  sub-crepitant  rale, 
followed,  not  by  bronchophony,  but  by  sub-mucous  and  mucous  rales. 
The  rales  in  pneumonia  or  the  bronchophony  are  audible  at  the  seat 
of  inflammation  only — in  bronchitis,  they  are  diffused  over  the  chest. 
An  uncomplicated  pneumonia  differs  from  a  pleuro-pneumonia  in  the 
following  particulars  :  In  pleuro-pneumonia  there  is  more  acute  pain, 
a  friction  murmur  as  well  as  a  crepitant  rale,  displacement  of  the 
heart  and  of  other  organs  by  the  fluid,  more  absolute  dullness  on  per- 
cussion, and  less  of  the  tympanitic  quality  to  the  percussion-note. 
Cases  of  pneumonia  with  cerebral  symptoms  may  be  mistaken  for 
meningitis,  but  this  can  only  happen  should  the  chest  not  be  exam- 
ined. In  pneumonia  of  the  aged,  and,  in  some  cases,  in  subjects  of 
delirium  tremens,  there  may  be  no  cough  or  other  rational  symptom 
to  direct  attention  to  the  chest. 

Treatment. — As  we  have  to  deal  with  a  self -limited  disease,  which 
terminates  by  crisis  between  the  fifth  and  the  eighth  day  in  sixty  per 
cent,  of  the  cases,  and  as  we  possess  no  specific,  it  is  obviously  our 
duty  not  to  interfere  too  zealously  in  natural  processes,  and  prevent, 
by  our  injudicious  handling,  a  favorable  termination.  Furthermore, 
the  so-called  expectant  jDlan,  as  pursued  by  moderns,  is  greatly  more 
successful  than  the  spoliative  plan  by  bloodletting  and  tartar  emetic, 
pursued  by  the  physicians  of  forty  years  ago.  Cautious  treatment  is 
all  the  more  necessary,  since  the  diatheses  are  so  largely  concerned  in 
the  origin,  the  evolution,  and  the  termination  of  this  disease.  The 
constitutional  tendencies,  the  actual  state,  and  the  surrounding  cir- 
cumstances should  receive  careful  attention  in  deciding  on  a  plan  of 
treatment.  A  vigorous,  healthy  subject,  free  from,  constitutional  vice, 
will  require  and  bear  a  more  vigorous  handling  than  a  broken-down 
alcoholic.     If  seen  at  the  beginning,  during  the  stage  of  congestion, 


PNEUMONIA.  339 

the  author  believes  that  much  may  be  accomplished  in  an  ordinarj'- 
case  by  a  full  dose  of  quinia  and  morphia  (3j — gr.  ss.),  the  application 
of  cups  or  leeches,  and  small  and  frequently  repeated  doses  of  the  tinc- 
ture of  aconite-root  (two  drops  every  two  hours).  At  the  same  time  a 
large  mustard-poultice  should  be  put  on  the  chest,  and  removed  when 
the  skin  is  reddened,  to  obtain  its  stimulant  effect  on  the  vaso-motor 
nerves  within,  and  the  feet  should  be  immersed  in  a  hot  mustard  foot- 
bath. When  the  quinia  and  morphia  have  been  absorbed,  an  active 
purgative  should  be  administered,  for  this  also  serves  to  diminish  the 
abnormal  blood-pressure.  If  the  viscid  secretion  is  pouring  out  in  the 
air-sacs  and  bronchioles,  and  coagulating,  it  is  necessary  to  use  some 
agent  which  possesses  the  power  to  lessen  the  viscidity  and  coagula- 
tion. Hughes  Bennett  employed  the  potassa  salts  (liquor  potassse 
eitratis)  or  an  extemporaneous  solution  of  the  bicarbonate,  and  his 
results  were  admirable.  Ammonia,  originally  suggested  by  Richard- 
son, has  been  latterly  used  more  freely  than  potassa,  and,  as  the  author 
believes,  with  better  results.  Probably  the  most  advantageous  method 
of  administering  it  is  the  solution  of  the  carbonate  in  liquor  ammonii 
acetatis  (  3  ss. — gr.  v  to  x)  every  three  or  four  hours.  By  the  German 
school  the  muriate  is  preferred  in  corresponding  doses,  but  it  does  not 
appear  to  the  author  to  be  so  useful.  The  ammonia  solution  should  be 
continued  up  to  the  crisis.  As  soon  as  consolidation  of  the  lung  is  ac- 
complished, all  arterial  sedatives  of  every  kind  should  be  discontinued. 
The  tincture  of  aconite,  or  the  more  powerful  tincture  of  veratrum 
viride,  may  be  given  with  undoubtedly  good  effects  during  the  stage 
of  congestion,  provided  the  subject  is  robust,  but  they  cease  to  be 
useful  when  red  hepatization  has  resulted,  for  then  already  arterial 
ischaemia  and  over-distention  of  the  veins  exist — a  state  of  things 
which  can  only  be  increased  by  cardiac  sedatives.  During  this  stage 
the  temperature  is  high,  and  hence  the  necessity  for  measures  to  re- 
strain it.  Assuming  that  pneumonia  is  a  specific  disease,  like  typhoid, 
Juergensen  *  maintains  the  necessity  for  the  use  of  antipyretics,  among 
which  he  places  the  cold  bath  first ;  and  the  success  of  his  treatment 
certainly  seems  to  justify  his  theory.  He  demonstrates  that  there  is 
no  danger  in  putting  a  pneumonic  patient  in  a  bath,  and  that  the  re- 
duction of  temperature  by  it  exercises  a  favorable  influence  over  the 
progress  of  the  disease.  ISText  to  the  bath  quinia  is  most  useful  as  an 
agent  for  reducing  fever,  but  it  must  be  given  in  scruple-doses  every 
four  hours  until  the  temperature  falls  to  a  proper  point,  when  it 
may  be  suspended  until  the  temperature  rises  again  in  twenty-four  to 
thirty-six  hours.  To  reduce  the  temperature,  Juergensen  regards  as 
so  important,  that  in  the  absence  of  the  means  for  a  cold  bath  he  sug- 
gests exposing  the  patient  naked  to  cold  air.     If  there  is  much  depres- 

*  Ziemssen's  "  Cyclopfedia,"  op.  cit. 


340  DISEASES  OF  THE  RESPIRATORY  ORGAN'S. 

sion  during  this  period  (red  hepatization),  quinia  may  be  given  in 
stimulant  doses  (three  grains  every  three  hours),  and  alcoholic  stimu- 
lants must  be  cautiously  administered — half  an  ounce  to  an  ounce  of 
whisky  or  brandy  every  three  hours.  As  the  period  of  crasis  ap- 
proaches, the  utmost  circumspection  is  necessary  ;  the  sudden  defer- 
vescence and  the  occurrence  of  some  exhausting  discharge  may  tax  too 
severely  the  vital  powers.  Suitable  aliment,  and  appropriate  stimulants, 
carefully  administered,  may  then  save  life. 

The  author  feels  it  necessary  to  emphasize  the  evil  effects  of  car- 
diac sedatives  during  the  stage  of  exudation  and  of  coagulation  of 
the  exudate.  The  administration  of  veratrum  viride,  digitalis,  aconite, 
and  tartar  emetic,  can  only  add  to  the  burden  of  the  heart,  already 
laboring  in  consequence  of  the  stasis  on  the  venous  side,  and  lack  of 
blood  on  the  arterial  side.  Paralysis  of  the  heart  is  one  of  the  most 
imminent  dangers,  because  of  this  state.  It  is  true  that  a  continued 
high  temperature  contributes  to  bring  about  paralysis  of  the  heart, 
but  we  possess  the  means  of  correcting  this  by  the  administration  of 
quinia,  and  by  cold  baths  or  the  cold  wet  pack.  While  arterial  and 
cardiac  sedatives  are  to  be  avoided  at  the  stage  of  red  hepatization, 
it  is  necessary  also  to  avoid  the  immoderate  use  of  alcoholic  stimu- 
lants. These  are  needed,  and  in  full  doses  in  inebriates  at  the  period 
of  crisis,  and  when  the  stage  of  purulent  transformation  is  reached 
there  are  a  rapid  and  weak  pulse,  a  relaxed  and  clammy  skin,  and 
delirium.  Protracted  wakefulness  and  delirium  need  careful  manage- 
ment. Opium  or  morphia  must  be  avoided,  owing  to  the  state  of 
the  pulmonary  circulation,  and  the  collateral  hypersemia  and  oedema. 
Then  it  is  that  chloral  hydrate  serves  a  most  useful  purpose  ;  it  pro- 
cures sleep,  quiets  delirium,  and  has  a  good  effect  on  the  exudation. 
Care  must  be  exercised,  for  large  or  frequently  repeated  doses  may  cause 
paralysis  of  the  heart ;  fifteen  grains  at  night,  with  ten  more  in  two 
or  four  hours,  if  the  first  dose  is  insufficient,  is  all  that  is  required 
usually.  Aliment  must  be  carefully  administered  from  the  beginning, 
without  waiting  for  depression  to  come  on.  Beef-juice,  milk,  egg- 
flip,  wine-whey,  chicken  or  mutton  broth,  etc.,  should  be  systematically 
administered  every  three  hours.  In  weak  subjects,  a  little  wine  may  be 
given  from  the  beginning.  As  already  stated,  the  pneumonia  of  the 
inebriate  requires  alcoholic  stimulants  from  the  first  symptom — for 
the  delirium  accompanying  it  is  due  largely  to  the  sudden  withdrawal 
of  the  supply,  or  the  inability  to  retain  it.  Much  has  been  said  about 
the  blistering-point  in  pneumonia.  Counter-irritation  is  useful  during 
the  stage  of  congestion,  as  already  indicated,  but  a  fugitive  counter- 
irritant,  as  a  mustard-plaster,  is  all  that  can  be  properly  used.  When 
the  crisis  occurs,  a  blister  is  very  useful.  During  the  stage  of  red  hepa- 
tization, turpentine-stupes,  cotton  wadding,  or  a  flannel  jacket,  is  use- 
ful unless  the  temperature  is  very  high,  when  they  do  mischief.     Fly- 


EMBOLIC   PNEUMONIA.  34I 

ing-blisters  are  serviceable  in  promoting  absorption,  when  resolution 
is  imperfect  and  exudations  still  linger  at  the  site  of  inflammation. 
To  facilitate  absorption  in  chronic,  succeeding  to  acute  pneumonia, 
the  iodide  of  ammonium  is  highly  beneficial.  It  may  be  administered 
with  the  iodide  of  iron,  and  in  conjunction  with  the  hypophosphites. 
If  there  are  "  prune-juice "  expectoration,  weak  pulse,  relaxed  and 
sweating  skin,  turpentine  in  small  doses,  or  eucalyptol,  is  extremely 
useful.  During  gray  hepatization,  they  may  be  given  for  the  double 
purpose  of  acting  on  the  organ  by  which  they  are  eliminated,  and  as 
cardiac  stimulants. 


EMBOLIC   PNEUMONIA— PNEUMONIA   FROM   EMBOLISM. 

Definition. — ^j  embolic  p7ieicmonia  is  meant  an  infarction  of  the 
lung,  due  to  embolic  blocking  of  a  vessel. 

Causes. — From  the  right  cavities  of  the  heart,  or  from  some  part 
of  the  venous  system,  an  embolus  is  dislodged,  and,  entering  the  cur- 
rent of  the  blood,  is  deposited  in  a  branch  of  the  pulmonary  artery. 
The  circumstances  under  which  clots  form  in  the  right  cavities  of 
the  heart  have  been  set  forth  elsewhere. 

Pathological  Anatomy.*— The  emboli  which  give  rise  to  embolic 
pneumonia  are  of  two  kinds,  simple  or  non-infective  and  infective. 
The  former  act  in  a  merely  mechanical  manner  by  closing  the  vessels 
and  preventing  the  pass'age  of  blood  to  the  parts  supplied  by  them  ; 
the  latter  not  only  obstruct  vessels  like  the  former,  but  the  infective 
material  contained  in  them  sets  up  a  local  infectious  process.  The 
size  of  the  embolus,  and  consequently  the  capacity  of  the  vessel  ob- 
structed, varies  considerably,  the  resulting  infarction  being  from  a  pea 
to  a  hen's-egg  in  size.  If  a  simple  embolus,  the  damage  is  confined  to 
the  area  occupied  by  the  infarction  ;  but,  if  an  infective  embolus,  a  sup- 
purative inflammation  arises  and  an  abscess  is  the  result.  To  the  for- 
mation of  an  infarction  it  is  necessary  that  the  embolus  lodge  in  a 
terminal  artery  of  Cohnheim — an  artery  without  anastomoses — for,  if 
the  obstructed  artery  is  connected  by  branches  with  others,  the  circu- 
lation in  the  obstructed  area  may  be  restored  through  collateral  chan- 
nels. If  the  obstructed  artery  be  a  terminal  one,  as  are  those  of  the 
outer  part  of  the  lung  in  a  restricted  sense,  the  pressure  in  the  veins 
causes  a  gradual  filling  of  the  obstructed  vessels  through  the  capilla- 
ries. Now,  as  the  walls  of  these  obstructed  vessels  are  not  properly 
nourished  by  the  blood  thus  in  a  state  of  stasis,  the  blood  diffuses 
through  into  the  surrounding  textures,  which  constitutes  the  infarction. 
Such  an  infarction  is  not  often  possible  at  the  root  of  the  lung,  for  here 
the  anastomoses  are  too  numerous,  although  they  do  sometimes  occur ; 

*  In  the  account  of  this  process,  Cohnheim's  classical  work,  "  Untersuchungen  ueber 
die  embolischen  Processe,"  Berlin,  1872,  Hirschwald,  p.  112,  is  followed. 


342  DISEASES   OF   THE   RESPIRATORY   ORGANS. 

but  it  is  at  the  periphery  that  they  usually  form.  As  the  vessels  pro- 
ceeding from  the  root  of  the  lung  toward  the  periphery  divide  dichot- 
omously,  it  is  obvious  that,  when  an  embolus  obstructs  one,  the  result- 
ing infarction  must  be  wedge-shaped — the  base  of  the  wedge  being 
toward  the  periphery  of  the  lung,  or  outwardly.  If  a  section  be  made 
through  an  infarction,  its  outline  will  be  seen  rather  sharply  defined, 
its  color  of  a  deep  blood-red,  and  it  will  exude  blood  on  slight  pressure. 
If  it  has  been  formed  for  some  time,  its  structure  is  denser  from  an 
infiltration  of  the  alveoli,  whence  it  presents  a  granular  appearance  ; 
it  is  dark-brownish  in  color,  is  drier,  and  exudes  but  little  blood,  and 
is  very  friable,  easily  breaking  up  into  a  pulverulent  mass.  The  bronchi 
contain  a  frothy,  bloody  fluid.  The  tissue  of  the  lung  about  the  in- 
farction becomes  hyperaemic  and  (Edematous.  The  pleura  overlying 
it  is  deeply  congested,  or  it  may  be  inflamed  and  coated  with  a  firmly 
adherent  albuminous  exudation,  while  the  cavity  contains  more  or  less 
bloody  serum.  The  infarction  undergoes  various  changes  ;  the  blood 
is  gradually  transformed,  becomes  fatty,  and  is  absorbed,  although 
patches  of  altered  hsematin  remain  ;  the  proper  tissue  of  the  lung 
undergoes  atrophy,  the  connective  tissue  multiplies,  and  in  this  way  a 
cure  is  effected,  the  lung  being  rendered  useless  to  the  extent  of  the 
infarction.  In  other  cases  an  embolic  abscess  is  produced,  the  embolus 
being  infective  ;  but  it  does  not  have  a  wedge-shape  ;  it  is  globular, 
and  presents  the  appearance  of  an  ordinary  purulent  collection.  In 
rare  cases  an  infarction  becomes  gangrenous.  Infarctions  are  found 
more  frequently  in  the  right  lung. 

Symptoms. — As  the  embolus  proceeds  most  frequently  from  the 
right  side  of  the  heart,  the  clinical  history  is  that  of  some  cardiac  dis- 
ease ;  but  it  may  be  produced  in  some  distant  part  of  the  venous  sys- 
tem under  circumstances  which  favor  thrombosis.  The  prominence 
and  urgency  of  the  symptoms  will  depend  on  the  size  of  the  infarction. 
If  it  be  small  in  extent,  there  may  be  no  disturbance  ;  even  if  quite 
large,  the  symptoms  may  be  masked  by  the  coexistent  disease.  If  a 
large  branch  of  the  pulmonary  artery  be  suddenly  closed,  there  will  be 
acute  dyspnoea  of  extreme  severity,  the  patient  will  gasp  for  breath, 
become  deeply  cyanosed  in  a  few  minutes,  and,  may  be,  die  at  once. 
Sudden  difficulty  of  breathing  is  the  most  significant  symptom  at  the 
time  of  lodgment  of  the  embolus,  especially  if  there  is  nothing  in  the 
condition  of  the  heart  to  account  for  the  dyspnoea.  Fever  comes  on 
some  days  after  the  obstruction,  but  the  rise  of  temperature  is  not  very 
great.  There  may  be  chills,  but  they  are  not  constant,  except  in  the 
case  of  pyaemia.  Bloody  expectoration  appears  in  a  few  days  after  the 
initial  dyspnoea,  and  is  usually  inconsiderable  in  quantity.  Besides 
blood,  there  is  a  viscid  mucus  which  is  the  body  of  the  sputa,  and,  as 
it  adheres  rather  tenaciously,  a  good  deal  of  coughing  is  necessary  to 
bring  it  up.     Pain  begins  with  the  implication  of  the  pleura,  and  has 


CATARRHAL  PXEUMOXIA.  343 

the  usual  characteristics  of  pleuritic  pain  :  it  is  acute  and  lancinating, 
and  is  increased  by  the  movements  of  respiration.  There  are  present 
the  usual  physical  signs  of  consolidated  lung — dullness  on  percussion, 
bronchial  voice,  and  bronchial  breathing.  There  may  be  a  friction- 
sound  due  to  the  pleuritis,  and  also  the  evidences  of  effusion  into  the 
pleural  cavity.  It  is  obvious  that  the  diagnosis  of  embolic  pneumonia 
is  difficult  and  uncertain.  The  sudden  occurrence  of  dyspnoea,  followed 
by  bloody  expectoration  continuing  eight  or  ten  days,  and  the  evi- 
dences of  consolidation,  are  the  only  symptoms  to  indicate  the  real 
nature  of  the  malady.  If  the  history  furnished  the  source  of  the  em- 
bolus, the  diagnosis  would  be  proportionally  facilitated.  The  prog- 
nosis is  generally  unfavorable,  notwithstanding  small  infarctions  may 
get  well.  There  is  no  plan  of  treatment  which  can  affect  a  mechanical 
condition  of  this  kind,  unless  ammonia  may  dissolve  an  embolus.  This 
should  be  tried. 

CATARRHAL   PNEUMONIA. 

Definition.  —  Various  terms  have  been  applied  to  this  disease,  as 
capillary  hroncliitis,  lobular  pneumonia,  hroncho-pneumonia,  etc.  As 
right  views  with  regard  to  it  are  necessary  to  a  proper  conception  of 
pulmonary  consumption,  it  is  discussed  here  somewhat  in  advance  of 
its  proper  position.  By  the  term  catarrhal  pneumonia  is  meant  a 
catarrhal  inflammation  involving  the  bronchioles  and  alveoli.  It  may 
be  acute  or  chronic. 

Causes. — Catarrhal  pneumonia  may  be  an  extension  downward  of  a 
catarrhal  process  beginning  in  the  bronchial  tubes.  It  is  jDrobable  that 
a  catarrhal  inflammation  never  begins,  under  any  circumstances,  in 
the  alveoli.  Typical  examples  of  this  disease  occur  during  certain 
of  the  exanthemata,  notably  measles  and  whooping-cough.  It  is  inti- 
mately associated  with  certain  diatheses,  as  rickets  and  scrofula,  and 
with  structural  alterations  of  the  heart  and  lungs,  as  mitral  lesions  and 
emphysema.  It  is  frequent  in  early  life  and  in  old  age,  and  is  less  so 
at  the  period  of  greatest  bodily  vigor.  Bad  hygienic  influences  as  to 
dress,  habitations,  humidity,  and  exposure,  favor  its  development.  Cli- 
mate is  an  important  factor,  and  the  period  of  most  extreme  variations 
is  the  period  of  greatest  prevalence  of  this  disease. 

Symptoms. — The  acute  form  is  the  type  ;  the  chronic  differs  from' 
it  merely  in  duration  and  severity  of  the  symptoms. 

The  initial  symptoms  are  chilliness  followed  by  fever,  soreness  of 
the  chest,  chiefly  beneath  the  sternum,  cough,  and  expectoration  of  a 
frothy  mucus,  and  some  difficulty  of  breathing.  These  symptoms  in 
the  acute  form  of  the  disease  quickly  develop  into  the  more  serious 
and  characteristic  proper  to  catarrh  of  the  finer  bronchial  tubes.  An 
abundant  secretion,  poured  out  all  along  the  bronchial  tree,  must  greatly 
affect  the  functions  of  the  lungs.     The  breathing  soon  becomes  rapid. 


344  DISEASES   OF  THE   EESPIRATORY   ORGANS. 

superficial,  and  labored,  the  accessory  muscles  of  respiration  are  brought 
into  play,  and  the  ala3  of  the  nose  work  quickly  and  continuously  ;  the 
face  is  at  first  flushed  and  rather  animated,  and  the  eyes  have  a  glaring- 
expression,  but  the  lips  soon  become  bluish  and  cyanosis  spreads  over 
the  face.  The  cough  in  the  first  onset  is  rather  loud  and  bronchial, 
but,  as  the  finer  tubes  become  involved,  it  has  more  of  a  stridulous, 
husky  character,  and  is  often  suppressed  and  partial  because  the  difii- 
culty  of  breathing  is  too  great  to  permit  the  necessary  expansion  of  the 
chest.  The  cough  is  also  painful,  and  in  children  is  attended  with 
moans  and  crying,  and  they  make  attempts  to  restrain  it  because  of 
the  soreness  in  the  chest.  The  fever  soon  rises  to  the  maximum  of 
104°  to  105°,  and  is  nearly  continuous,  there  being  a  slight  morning 
remission.  As  the  difiiculty  of  breathing  develops,  there  is  increasing 
restlessness,  never  a  moment  of  quiet,  the  struggle  for  breath  and  the 
search  for  an  easier  position  being  incessant.  At  first  there  are  brief 
snatches  of  uneasy  sleep,  but,  as  the  dyspnoea  increases,  a  state  of 
somnolence  comes  on  which  gradually  deepens  into  coma,  so  profound 
at  length  that  cough  is  suppressed.  This  somnolence  is  due  to  the 
deficient  aeration  of  the  blood  and  the  accumulation  of  carbonic  acid. 
Finally,  the  blood  becomes  wholly  venous.  Then  the  flush  disappears 
fi'om  the  face  and  is  replaced  by  a  death-like  pallor,  the  cyanosis  deep- 
ens about  the  lips,  blue  spots  appear  on  the  cheeks,  and  the  superficial 
veins  grow  into  thick  black  cords.  The  struggle  for  breath  continu- 
ing, while  the  carbonic- acid  poisoning  increases,  the  most  frantic  but 
largely  automatic  efforts  are  made  to  remove  supposed  obstructions, 
and  the  patient,  a  child,  may  tear  its  skin  about  the  neck  and  face  with 
its  nails,  in  the  vain  effort  to  remove  them.  On  inspection,  the  cervi- 
cal and  other  muscles  auxiliary  are  seen  actively  engaged,  and  a  deep 
depression  of  the  abdomen  from  retraction  of  the  lower  ribs  is  made 
with  every  strong  inspiration.  On  palpation,  the  vocal  fremitus  will 
be  unaffected  during  the  first  few  days,  but,  when  the  lobules  have 
collapsed  in  considerable  numbers,  the  physical  conditions  are  changed, 
and  the  vocal  fremitus  will  then  be  increased.  On  auscultation,  rales 
are  abundant  all  over  the  chest  ;  they  consist  of  sub-crepitant  rales, 
which  are  somewhat  coarser  and  louder  than  the  crepitant,  and  are 
audible  with  both  inspiration  and  expiration.  With  these  also  occur 
mucous  and  sub-mucous  rales,  produced  in  the  larger  tubes.  The 
respiratory  murmur  becomes  more  and  more  feeble  as  the  condition 
of  atelectasis  is  produced  ;  and,  when  a  number  of  lobules  are  thus 
affected,  over  them  the  respiratory  murmur  ceases  to  be  audible,  a 
blowing  sound  is  substituted,  and  this  passes  into  bronchial  breathing 
and  bronchophony  as  the  pulmonary  tissue  becomes  consolidated.  On 
percussion  there  is  no  change  until  the  atelectasis  occurs  ;  the  sonority  is 
diminished  as  the  lobules  collapse,  until  dullness  is  reached  ;  but  the 
dullness  has  much  of  the  tympanitic  quality,  owing  to  the  jjroximity  of 


CATARRHAL   PNEUMONIA.  345 

unobstructed  alveoli.  In  making  percussion  in  children,  it  is  important 
to  strike  lightly,  otherwise  the  primary  bronchi  and  trachea  will  be 
thrown  into  vibration.  The  pulse-rate  does  not  always  correspond 
to  the  range  of  temperature  ;  it  is  usually  higher.  The  pulse  ranges 
from  140  to  200  or  more  in  children,  while  in  the  aged  it  may  be  but 
little  accelerated.  Protracted  high  temperature  may  induce  changes 
— parenchymatous  degeneration  of  the  cardiac  muscle.  If,  therefore, 
during  the  course  of  this  disease  the  pulse  becomes  feeble,  irregular, 
and  very  rapid,  the  condition  of  the  heart  is  one  to  arouse  great  solici- 
tude. The  appetite  is  poor,  vomiting  often  occurs,  and  dian-hoea  is 
by  no  means  infrequent.  The  embarrassment  to  breathing  caused  by 
the  act  of  eating  and  swallowing  induces  young  children  to  avoid  eat- 
ing solid  food,  although  they  will  often  drink  greedily.  Cerebral 
symptoms  are  present  to  a  greater  or  less  extent  in  all  cases  :  there 
may  be  headache,  hallucinations,  muscular  twitchings,  even  convul- 
sions, and  the  coma  of  carbonic-acid  poisoning.  So  closely  do  the 
nervous  symptoms  belonging  to  catarrhal  pneumonia  simulate  those  of 
tubercular  meningitis  that  it  may  be  exceedingly  difficult  to  diagnos- 
ticate between  them.  In  the  chronic  or,  rather,  subacute  form  of 
catarrhal  pneumonia  the  development  is  slow,  the  fever  of  moderate 
intensity,  and  the  difficulty  of  breathing  not  pronounced.  If  there 
has  been  an  attack  of  acute  bronchitis,  or  of  whooping-cough  with 
more  or  less  extensive  bronchitis,  when  the  catarrhal  pneumonia  de- 
velops, the  cough  subsides,  but  the  depression  of  the  vital  forces,  the 
cyanosis,  and  the  extreme  emaciation,  indicate  the  growth  of  the  more 
serious  lesions.  When  these  cases  tend  toward  a  fatal  termination,  the 
grave  symptoms  just  mentioned  increase,  and  carbonic-acid  poisoning 
comes  on,  death  occurring  in  more  or  less  profound  coma.  Some  cases 
pursue  a  different  course  ;  after  a  protracted  subacute  period  in  which 
the  pulmonary  lesions  begin,  an  acute  attack  arises,  and  then  the  sub- 
sequent behavior  is  that  of  an  ordinary  acute  case,  death  occurring  in 
coma.  When  they  tend  to  recovery,  there  is  a  gradual  improvement 
in  all  the  symptoms  :  the  cyanosis  diminishes,  the  dyspnoea  lessens, 
the  appetite  improves,  and  gradually  the  general  health  is  in  part  re- 
stored, the  lungs  imperfectly  repaired. 

Pathological  Anatomy. — The  changes  involve  the  bronchial  tubes 
and  the  lungs.  The  mucous  membrane  is  the  seat  of  an  hypersemia 
from  the  larynx  down,  but  it  increases  in  severity  downward,  reaching 
the  maximum  at  the  most  dependent  part  of  the  lungs.  The  vessels 
are  so  deeply  injected  that  the  mucous  membrane  is  a  dark  red,  and  at 
various  points  there  are  extravasations.  The  finer  tubes  are  filled  with 
a  quantity  of  yellowish,  creamy,  purulent  fluid.  On  section  of  the 
lung,  drops  of  this  exudation,  escaping  from  the  tubes,  look  just  like 
pus  escaping  from  a  small  abscess,  especially  if  the  divided  tube  has 
undergone  dilatation — a  change  which  takes  place  in  the  more  pro- 


3i6  DISEASES   OF   THE   EESPIRATORT   ORGANS. 

tracted  cases.  This  pus  is  probably  made  up  of  the  young  cells  de- 
rived by  multiplijcation  of  the  epitheliuin,  but  especially  of  the  lymphoid 
cells  which  migrate  from  the  vessels,  and  are  found  in  the  sub-mucous 
connective  tissue,  in  the  alveoli,  and  in  the  bronchioles.  There  are 
two  opinions  now  entertained  in  respect  to  the  cellular  elements  which 
crowd  the  alveoli,  and  as  to  the  part  taken  by  the  j)avement  epithelium. 
Among  others,  Rindfleisch  maintains  that  these  cells  are  produced  by 
the  multiplication  of  the  epithelium,  and  derived  in  part  from  the  pro- 
liferation of  the  lymphoid  cells  ;  others,  again,  notably  Buhl,  deny  the 
participation  of  the  epithelium,  and  maintain  that  the  products  of  the 
catarrhal  inflammation  are  drawn  into  the  alveoli  by  a  species  of  suc- 
tion. Besides  the  changes  in  the  mucous  membrane,  the  bronchial 
tubes  and  intervening  connective  tissue  take  part.  The  bronchioles 
undergo  dilatation  if  they  have  been  long  subjected  to  the  inflamma- 
tion, and  the  connective  tissue  undergoes  hyperplasia,  attaining  to 
very  considerable  development.  The  formation  of  the  very  viscid 
exudation  which  takes  place  at  the  beginning  of  the  process  and  the 
swelling  of  the  mucous  membrane  are  important  elements  in  the  col- 
lapse of  the  lobules  (atelectasis)  which  is  a  conspicuous  result  in  the 
sum  of  pathological  changes.  The  collapse  of  the  lobules  takes  place 
before  the  alveoli  which  form  them  are  crowded  with  the  products  of 
the  catarrhal  inflammation.  The  mechanism  of  the  collai^se  is  about 
as  follows  :  In  the  strong  efforts  in  coughing  or  in  expiration,  or  both, 
the  air  is  forced  out  through  the  swollen  tubes  ;  and,  when  the  air  has 
passed,  the  surfaces  are  brought  into  contact,  and  are  made  to  adhere 
tenaciously.  All  of  the  residual  air  is  gradually  expelled  in  this  way  ; 
but,  in  the  efforts  at  inspiration,  the  force  is  insufficient  to  separate  the 
adherent  surfaces,  and,  as  the  pressure  is  immediately  increased  in  the 
adjacent  lobules,  the  collapsed  lobule  is  also  compressed.  The  collapsed 
lobules  are  easily  recognized  by  their  appearance,  which  is  of  a  dark- 
blue  or  purplish-blue  color  ;  they  are  much  firmer,  do  not  crepitate, 
because  they  contain  no  air,  and  exude  but  little  blood  on  section. 
The  extent  to  which  this  process  is  carried  varies  in  different  cases. 
It  begins  in  the  most  dependent  part  of  the  lungs,  and  advances  for- 
ward and  upward,  involving  much,  sometimes  the  whole,  of  the  lower 
lobe.  In  some  chronic  cases  the  process  takes  place  chiefly  in  the 
upper  lobes.  Collapse  of  some  lobules,  the  pressure  continuing  the 
same,  necessarily  involves  the  dilatation  of  others,  and  in  this  way 
emphysema  results,  the  anterior  portions  of  the  lungs  being  affected 
chiefly.  Attacks  of  catarrhal  pneumonia  in  eai'ly  life,  imperfect  repair 
only  taking  place,  have  much  to  do  with  the  subsequent  development 
of  emphysema.  After  the  lobules  have  collapsed,  for  a  short  period  they 
continue  permeable  to  air  and  may  be  inflated.  The  change  in  color 
and  density  which  occurs  when  the  collapse  is  effected  is  often  mis- 
taken for  inflammation — whence  the  term  "  lobular  pneumonia."     If 


CATARRHAL   PNEUMONIA.  347 

the  collapse  continue,  an  inflammatory  j^rocess  is  set  up,  similar  to  but 
not  identical  with  that  of  croupous  pneumonia,  for  it  never  becomes 
granular.  The  inflamed  part  becomes  more  solid,  is  of  a  dark-brown 
color,  which  terminates  in  grayish  red  ;  it  begins  in  the  center  of  the 
lobules  and  spreads  outwardly  ;  neighboring  lobules  affected  in  the 
same  way  coalesce,  until  ultimately  a  whole  lobe  may  be  involved. 
Then  it  presents  to  the  eye,  when  the  process  is  completed,  a  bluish- 
gray  appearance  ;  on  section  it  is  found  to  be  homogeneous,  very  firm, 
and  tough.  Before  this  final  stage  is  completed  it  is  very  friable. 
The  purulent  matter  in  the  bonchi  and  the  catarrhal  products  in  the 
alveoli  undergo  the  cheesy  transformation.  The  subsequent  history 
is  that  of  "  caseous  pneumonia."  Those  portions  of  the  pleura  in  con- 
tact with  the  inflamed  lobules  become  hyperferaic,  inflame,  an  exuda- 
tion is  poured  out,  and  adhesions  form,  or  effusion  takes  place  in  the 
thoracic  cavity.  Not  every  case  tends  to  death,  or  to  the  chronic 
changes  above  described.  Partial  recovery  ensues  in  a  considerable 
number,  complete  recovery  in  but  few.  When  the  collapsed  lobules 
inflame,  unless  there  be  but  few,  restoration  seems  hardly  possible 
even  in  the  sense  of  a  partly  useless  lung.  If  the  lobules  are  capable 
of  being  distended  again  with  air,  and  the  catarrhal  inflammation  sub- 
sides in  the  bronchioles  and  alveoli,  a  cure  is  then  possible.  The 
purulent  contents  of  the  bronchi  are  brought  up  by  coughing,  and 
swallowed  or  expectorated  ;  the  watery  portion  of  the  exudation  in 
the  alveoli  is  absorbed  ;  the  cells  disintegrate,  become  granular  and 
fatty,  and  are  ultimately  absorbed — thus  restoring  the  alveoli  to  the 
admission  of  air.  The  fluid  and  the  cells  of  the  intervening  connec- 
tive tissue  pass  through  the  same  process,  and  thus  the  injured  part  is 
restored,  except  that  its  elasticity  continues  impaired  for  a  long  time. 

Complications  and  SequelSB. — The  complications  are  really  parts  of 
the  malady  in  its  entirety.  Bronchitis  is  always  present,  and  laryngitis 
frequently.  Pleuritis  is  a  necessary  result  when  the  peripheral  portion 
of  the  lung  is  involved.  The  sequelae  are  very  important.  As  was 
indicated  under  the  head  of  pathological  anatomy,  there  are  two  dis- 
eases which  result  from  catarrhal  pneumonia — emphysema  and  caseous 
pneumonia.  The  former  is  a  result  of  the  atelectasis  or  collapse  of  the 
lobules  ;  the  latter  is  an  outcome  of  the  changes  in  the  catarrhal  prod- 
ucts which  crowd  the  alveoli,  in  the  bronchi  themselves,  and  in  the  in- 
tervening connective  tissue.  In  the  account  to  be  presently  given  of 
these  diseases,  the  course  of  development  from  one  to  the  other  will  be 
set  forth. 

Course,  Duration,  and  Termination. — The  course  of  catarrhal  pneu- 
monia is  from  a  catarrh  of  the  larger  tubes  to  a  catarrh  involving  the 
ultimate  bronchioles,  and  probably  the  alveoli.  There  are  two  prin- 
cipal phases  in  the  subsequent  course  :  the  development  of  the  catar- 
rhal process  ;  the  collapse  of  the  lobules,  and  the  transformations  which 


348  DISEASES  OF  THE  RESPIRATOEY   ORGANS. 

they  undergo.  Restoration  may  occur  by  a  retrograde  change  in  the 
catarrhal  products  and  by  absorption,  and  the  collapsed  lobules  may  be 
again  expanded.  Often  the  restoration  is  partial,  and  the  lung  may 
remain  contracted  and  atrophied  at  the  site  of  the  collapsed  lobules. 
In  still  other  cases  the  bronchial  tubes  are  dilated,  the  connective  tissue 
undergoes  hyperplasia  and  thickening,  the  catarrhal  products  become 
caseous,  and  the  collapsed  lobules  slowly  inflame.  It  is  obvious  that 
the  duration  of  such  a  malady  must  be  subject  to  great  variations. 
The  simplest  case  of  catarrhal  pneumonia  can  hardly  be  concluded  in 
a  less  time  than  two  or  three  weeks.  In  fatal  cases,  death  may  occur 
in  a  day  or  two  or  within  a  week.  In  rapidly  fatal  cases  death  is  due 
to  such  a  blocking  of  the  bronchioles  that  the  blood  can  not  be  aerated, 
death  occurring  in  deep  coma  from  carbonic-acid  poisoning.  In  chronic 
cases  death  occurs  in  two  modes  :  by  an  acute  exacerbation  ;  by  grad- 
ual failure  of  the  vital  power,  by  the  changes  of  catarrhal  pneumonia, 
or  the  results  of  chronic  inflammation  in  the  collapsed  lobules.  In  a 
large  proportion  of  cases  of  catarrhal  pneumonia  in  which  recovery 
takes  place,  there  is  not  a  complete  restoration,  and  hence  the  produc- 
tion of  emphysema  in  after-years. 

Prognosis. — About  one  half  of  the  cases  of  catarrhal  pneumonia 
prove  fatal.  The  prognosis  must  be  guarded,  not  only  as  respects  im- 
mediate mortality,  but  the  future  prospects  of  such  patients.  The 
more  acute  the  attack  the  greater  the  danger  of  a  fatal  result,  for 
acuteness  in  the  attack  means  the  collapse  of  many  lobules.  The 
younger  the  subject  the  more  dangerous  an  acute  attack  is,  or  indeed 
any  attack  of  catarrhal  pneumonia.  Diatheses  play  an  important  part 
in  the  prognosis,  for  scrofulous  and  rachitic  subjects  are  less  able  to 
bear  up  under  the  inflammation.  The  prognosis  is  also  much  influ- 
enced by  the  bodily  state,  for  the  less  the  power  of  resistance  the  more 
severe  the  disease. 

Diagnosis. — Catarrhal  pneumonia  may  be  confounded  with  bron- 
chitis, croupous  pneumonia,  acute  tuberculosis,  and  cedema  of  the 
lungs.  From  simple  bronchitis,  capillary  bronchitis  is  separated  by 
the  size  of  the  moist  rales,  by  the  dyspnoea  in  the  one,  its  absence  in 
the  other  ;  by  the  signs  of  consolidation  of  the  lung-tissue  in  the  one, 
by  the  absence  of  such  consolidation  *  in  the  other  ;  and,  finally,  by 
the  subsequent  history  so  different  in  the  two  diseases.  Croupous 
pneumonia  is  unilateral,  or,  when  bilateral,  limited  to  a  certain  area  ; 
catarrhal  pneumonia  is  bilateral  and  diffused  over  both  lungs.  Besides 
the  difference  in  the  physical  signs  recapitulated  under  the  head  of 
croupous  pneumonia,  there  is  the  remarkable  difference  in  the  behavior, 
one  being  a  self-limited  disease,  the  other  having  no  fixed  duration. 
Acute  tuberculosis  at  its  onset  is  characterized  by  the  presence  of  a 
capillary  bronchitis,  so  that  a  differentiation  is  possible  only  by  a  study 
of  the  clinical  history  and  course  of  the  two  affections.    (Edema  of  the 


CATARRHAL  PNEUMONIA.  349 

lungs  is  accompanied  by  similar  symptoms  as  regards  the  dyspnoea  and 
the  physical  signs  ;  but  oedema  is  not  a  feverish  state,  and  it  is  accom- 
panied by  albuminuria  or  some  evident  cause. 

Treatment. — The  chief  source  of  danger  in  catarrhal  pneumonia  is 
the  universal  presence  of  a  viscid  secretion,  which  interferes  with  the 
entrance  of  air  and  thus  prevents  proper  oxygenation  of  the  blood, 
and  causes  collapse  of  the  lobules,  indirectly.  The  agents  most  useful 
to  diminish  the  viscidity  and  favor  the  excretion  of  the  exudation  are 
the  preparations  of  ammonia.  The  author  has  obtained  the  best  results 
from  the  carbonate  (three  to  six  grains)  and  the  iodide  of  ammonia 
(four  to  eight  grains)  in  solution  every  two  hours.  The  muriate  has 
been  much  prescribed  for  the  same  purpose,  but  the  iodide  and  carbon- 
ate are  more  efficient.  These  should  be  perseveringly  administered.  If 
the  symptoms  are  subacute,  the  oil  of  turpentine,  eucalyptol,  and  copaiba 
are  very  active  in  checking  the  formation  and  favoring  the  extrusion 
of  the  exudation  in  the  tubes.  Of  these,  probably  copaiba  is  the  best, 
as  it  may  be  more  energetically  pushed  than  the  others.  These  stim- 
ulating expectorants,  as  they  are  called,  owe  their  efficacy  chiefly  to 
the  fact  that  the  volatile  oil  which  they  contain  is  eliminated  by  the 
lungs  and  acts  locally.  They  may  be  used  in  the  acute  cases  also, 
after  the  subsidence  of  the  most  acute  symptoms,  and  at  the  same 
time  that  the  ammonia  preparations  are  administered.  If  there  be 
excessive  dyspnoea,  notwithstanding  the  use  of  these  remedies,  the 
accumulated  muco-pus  must  be  dislodged  by  emetics.  Apomorphia  is 
the  most  efficient  of  the  emetics,  and  can  be  administered  in  the  way 
to  secure  the  best  effects — by  hypodermatic  injection.  Great  care 
must  be  exercised  in  the  use  of  this  remedy,  since  occasionally  pro- 
found narcotism  is  produced  by  it,  probably  due  to  the  presence  of 
morphia.  The  author  has  used  the  subsulphate  of  mercury,  with 
most  excellent  effect,  as  an  emetic  in  catarrhal  pneumonia.  Although 
this  is  a  poisonous  substance,  no  danger  need  be  apprehended  from  it, 
since  it  comes  up  with  the  vomited  matters.  It  can  be  given  in  from 
two  to  four  grains  at  a  dose,  rubbed  up  with  some  sugar.  Besides 
its  emetic  action,  the  subsulphate  seems  to  have  the  power  to  check 
the  formation  of  the  muco-pus.  The  repetition  of  the  emetic  depends 
on  the  state  of  the  case — every  few  hours  it  may  be  administered  if 
the  dyspnoea  and  the  cyanosis  require  it.  The  immediate  result  of  the 
emetic  action  ought  to  be  an  improvement  in  the  difficulty  of  breath- 
ing and  lessening  of  the  cyanosis.  If  the  fever  is  great  and  the  arte- 
rial tension  high,  good  results  are  obtained  from  the  combined  use  of 
tincture  of  aconite-root  and  tincture  of  belladonna — two  drops  of  the 
former  and  four  drops  of  the  latter  to  a  child  of  two  years,  every  two 
hours.  Continued  high  temperature  demands  the  use  of  quinine  and 
digitalis.  To  a  child  of  two  years,  five  grains  of  quinia  and  one 
fourth  of  a  grain  of  digitalis  can  be  given  morning,  noon,  and  even- 


350  DISEASES   OF   THE   RESPIRATORY   ORGANS. 

ing,  until  the  temperature  and  pulse  are  brought  within  proper  limits, 
when  they  should  be  administered  at  longer  intervals.  As  this  dis- 
ease makes  enormous  demands  on  the  vital  resources,  the  strength 
should  be  maintained  by  suitable  nutrients  from  the  beginning.  Al- 
coholic stimulants  are  not  only  borne  well,  but  they  are  extremely 
serviceable,  and  seem  to  have  power  to  check  the  exudation.  Inhala- 
tions are  highly  useful.  The  air  of  the  apartment  should  be  kept 
moist  by  steam ;  but,  besides  this,  by  means  of  the  atomizer,  there 
should  be  directed  into  the  fauces  a  spray  of  solution  of  common  salt, 
ammonium  chloride,  or  potassio  chlorate.  If  the  spray  can  not  be 
borne  directly  into  the  fauces,  at  least  the  atmosphere  about  the 
patient  should  be  saturated  with  it.  In  the  subacute  and  chronic 
cases,  excellent  results  are  obtained  from  the  persistent  use  of  the 
iodide  of  ammonium,  conjoined  -with  the  administration  of  the  hypo- 
phosphites  and  lactophosphate  of  lime.  Counter-irritation  is  use- 
ful in  both  acute  and  chronic  cases.  During  the  acute  stage  mus- 
tard-plasters and  flying-blisters  are  serviceable,  but  the  mistake  should 
not  be  made  of  applying  deeply  acting  and  jDrolonged  counter-irri- 
tants, lest  the  irritability  of  the  organic  nervous  system  be  exhausted, 
and  the  lesions  within  promoted.  Turpentine-stupes,  warm,  are  gen- 
erally the  most  useful  application.  The  tincture  of  iodine  is  adajDted 
rather  to  the  subacute  and  chronic  than  to  the  acute  form.  Among 
the  occasional  expedients  employed  in  the  treatment  of  catarrhal 
pneumonia  is  the  inhalation  of  oxygen.  This  gives  great  relief  to  the 
dyspnoea,  although  it  does  not  modify  the  morbid  process  in  any  way, 
and  the  relief  is  temporary.  The  author  knows  of  no  case  in  which 
the  inhalations  were  continued  for  some  time  in  such  cases.  The  in- 
halation of  turpentine-vapor  might  be  carried  on  by  disengaging  the 
vapor  in  the  ajDartment  occupied  by  the  patient.  A  local  action  of 
some  value  might  thus  be  obtained,  since  it  is  apparent  that  the  effect 
of  this  agent  at  the  point  of  elimination  is  the  chief  source  of  its 
utility  Avhen  administered  by  the  stomach. 


PHTHISIS  PULMONALIS— PULMONARY   CONSUMPTION. 

Preliminary. — Three  forms  of  pulmonary  consumption  are  now  ad- 
mitted to  exist  :  caseous  phthisis  ;  tubercular  phthisis  ;  fibroid  phthisis. 
As  these  forms  present  differences  at  all  points,  it  will  conduce  to  clear- 
ness of  conception  to  treat  of  the  varieties  separately. 


1.   CASEOUS  PHTHISIS. 

Definition. — Caseous  phthisis  is  that  form  of  pulmonary  consumption 
characterized  by  the  caseation,  or  cheesy  degeneration,  of  inflammatory 
products  in  the  lungs,  and  the  subsequent  softening  and  extrusion  of  the 


PHTHISIS  PULMONALIS.  351 

caseous  matter,  with  greater  or  less  destruction  of  the  pulmonary 
tissue. 

Etiology. — The  chief  factor  in  the  etiology  of  caseous  i^hthisis  is 
catarrhal  pneumonia,  especially  of  the  apex,  although  it  may  be  in  any 
part  of  the  lung.  There  must,  however,  be  bodily  conditions  which 
favor  the  transformation  of  the  catarrhal  products  into  caseous,  since 
only  a  portion  of  the  cases  of  catarrhal  pneumonia  undergo  such  trans- 
formation. These  bodily  conditions  are  a  strumous  constitution,  or 
a  state  of  lowered  health,  produced  by  the  operation  of  various  evil 
hygienic  influences.  The  strumous  or  scrofulous  diathesis  is  charac- 
terized by  these  peculiarities  :  a  tendency  to  protracted  suppuration 
and  the  production  of  a  watery  and  ichorous  pus,  from  slight  injuries, 
and  having  little  or  no  disposition  to  terminate,  but  rather  to  con- 
tinue ;  and  the  occurrence  of  glandular  enlargements.  When  in  such 
a  type  of  constitution  a  catarrhal  process  is  set  up  in  a  part  of  the 
lungs,  the  products  of  such  process,  instead  of  undergoing  resolution 
or  some  form  of  organization,  caseate  or  become  transformed  into 
caseous  material.  We  have  in  this  fact  an  explanation  of  the  frequent 
association  of  measles  and  consumption.  Some  of  the  cases  affected 
to  the  same  extent  with  catarrhal  pneumonia  get  well,  because  there 
is  no  underlying  constitutional  state  to  invite  other  diseases  ;  some 
pass  into  caseous  pneumonia  and  phthisis,  because  they  are  tainted 
with  the  strumous  diathesis  ;  in  a  small  number  acute  miliary  tubercu- 
losis develops.  A  strumous  diathesis,  not  inherited,  may  be  gradually 
acquired  under  the  influence  of  bad  hygiene — as  living  in  a  dark, 
damp,  and  foul  habitation,  wath  insuflicient  and  improper  food,  and 
exhausted  by  overwork,  anxiety,  etc.  If  such  influences  are  not  suifi- 
cient  to  develop  the  strumous  diathesis,  at  least  they  cause  a  bodily 
state  in  which  caseation  readily  takes  place  in  the  imflammatory  prod- 
ucts of  catarrhal  pneumonia.  Caseous  phthisis  is  comparatively  com- 
mon in  early  life,  because  at  this  period  measles,  whooping-cough,  and 
catarrhal  pneumonia  frequently  occur.  It  may  happen  at  any  period, 
but  is  more  common  up  to  thirty-five  than  subsequently.  As  regards 
sex,  the  liability  to  this  form  of  phthisis,  it  seems  to  the  author,  is 
greater  in  the  female. 

Pathological  Anatomy. — In  the  description  of  the  pulmonary  lesions 
of  catarrhal  pneumonia,  it  was  shown  that  the  alveoli  of  the  lungs  are 
crowded  with  cells,  and  that  the  bronchioles  are  filled  with  yellowish 
muco-pus.  The  part  which  the  epithelium  of  the  alveoli  takes  in 
these  changes  is  disputed.  According  to  Rindfleisch  *  this  pavement 
epithelium  undergoes  desquamation  and  other  changes.  "The  cells 
first  become  looser,  their  attached  surfaces  are  covered  with  a  thick 
layer  of  finely  granular  protoplasm,  at  the  same  time  in  each  cell  the 

*  Zicmssen's  "  Cj-clopsedia,"  vol.  v,  p.  666. 


352  DISEASES   OF  THE   RESPIRATORY   ORGANS. 

nucleus,  whicli  was  before  hardly  visible,  becomes  swollen  and  is  seg- 
mented. Thus  are  formed  large  granular  epithelial  cells,  with  rounded, 
polygonal  contours,  and  containing  one  or  more  nuclei."  According 
to  Buhl,  the  alveoli  not  containing  a  mucous  membrane  can  not  un- 
dergo the  catarrhal  process,  and,  therefore,  the  cells  which  so  crowd 
the  alveoli  must  be  drawn  or  sucked  into  them.     Besides  the  cellu- 


'# 


*^^kii  "^ 


Fie.  27.— Caseous  Pneumonia.    (Thierfelder.) 

lar  elements  filling  the  bronchioles  and  alveoli,  an  enormous  infil- 
tration of  cells  takes  place  into  the  intervening  connective  tissue — 
"many  of  them  with  two  nuclei,  nearly  all  with  several  surfaces,  flat- 
tened." When  this  infiltration  of  cells  has  reached  the  point  of  dis- 
tending the  septa  between  the  alveoli,  the  vessels  are  so  compressed 
that  the  circulation  in  them  is  suspended.  Hyperplasia  of  the  connec- 
tive tissue,  although  denied  by  Rindfleisch,  does  take  place  according 
to  other  investigators,  and,  in  contracting,  considerable  shrinkage  oc- 
curs, and  a  dense  homogeneous  mass  results,  made  up  of  the  distended 
alveoli,  the  infiltrated  septa,  the  bronchioles  dilated  and  filled  with 
muco-pus  and  the  contracting  connective  tissue,  and  is  now  in  a  condi- 
tion preparatory  to  the  cheesy  transformation.  The  caseous  change 
consists  in  absorption  of  the  watery  parts,  the  fatty  degeneration  of 
the  cellular  elements,  and  granular  disintegration  of  the  fibrinous  ma- 
terial, so  that  ultimately  a  soft  solid  is  produced,  yellowish  in  color,  and 
having  the  appearance  of  cheese.  In  the  mass  are  inclosed  all  the  pul- 
monary elements — the  acini,  the  bronchioles,  the  vessels,  etc.  "  These 
nodules  are  surrounded  by  atelectatic,  oedematous,  or  gelatinous  paren- 
chyma in  the  preliminary  stage  of  desquamative  [catarrhal]  pneumo- 
nia." The  position  of  the  catarrhal  pneumonia  resulting  in  the,  changes 
described  is  usually  at  the  apex,  but  precisely  the  same  alterations 
occur  in  other  jjai'ts.     They  may  result  from  a  general  catarrhal  bron- 


PHTHISIS  PULMONALIS.  -  353 

chitis  which  has  subsided  elsewhere,  but  usually  the  disease  is  of  the 
subacute  form  already  described  in  the  previous  section,  and  limited,  as 
it  has  a  great  tendency  to  be,  to  the  apices  or  to  an  apex.  Sometimes 
a  whole  lobe,  a  whole  lung  (phthisis  florida),  becomes  infiltrated,  and 
undergoes  the  cheesy  degeneration.  The  softening  in  these  cheesy  nod- 
ules or  masses  begins  in  the  center,  and  consists  at  first  of  a  central 
cavity  and  softened  canals  extending  from  the  center  to  the  periphery. 
According  to  Rindfleisch,  the  cheesy  masses  in  the  lumina  of  the  bronchi 
are  the  first  to  soften,  while  that  in  the  peribronchial  and  perivascular 
spaces  resists  the  softening  process  for  some  time.  The  force  exerted 
in  respiration,  the  dilatation  of  the  bronchi,  and  the  contraction  of  the 
parenchyma  of  the  lungs,  are  the  agencies  which  procure  extrusion  of 
the  detritus.  Larger  cavities  are  formed  by  the  breaking  down  of  the 
divisions  between  smaller  ones.  The  shape,  size,  conformation,  and 
appearance  of  cavities  vary  with  their  age.  The  admission  of  air 
sets  up  putrefactive  changes,  and,  instead  of  an  odorless,  softened 
caseous  matter,  it  is  now  foul,  greenish,  or  grumous  matter.  When 
this  is  mixed  with  the  sputa,  elastic  fibers  are  detected  in  it,  and  the 
yellowish-gray  solid  particles,  which  are  so  characteristic  a  feature  of 
the  expectoration.  At  first,  the  iiaterior  of  the  cavity  is  irregular, 
rough,  and  is  more  or  less  full  of  disintegrating  pulmonary  tissue  and 
projecting  caseous  material ;  but,  when  all  this  is  discharged,  it  is  smooth, 
and  lined  with  a  connective-tissue  membrane,  which  furnishes  a  quantity 
of  purif  orm  fluid.  If  accumulation  of  the  purulent  contents  of  the  cavity 
takes  place,  putrid  decomposition  occurs,  and  the  pus  becomes  fetid. 
Haemorrhage  may  be  produced  by  erosion  of  a  branch  of  the  pulmonary 
artery.  This  accident  would  be  much  more  common,  if  it  were  not 
that  the  vessels  are  early  closed  and  cease  to  be  pervious.  In  rare 
cases  the  mischief  is  confined  to  one  or  a  few  localities.  Extrusion  of 
the  caseous  matter  occurs,  there  is  no  extension  of  the  morbid  process 
to  neighboring  tissue,  contraction  of  the  cavity  takes  place,  and  ulti- 
mately a  mass  of  rather  loose  connective  tissue  remains  to  mark  the 
site  of  the  disease.     This  is  the  only  mode  of  cure  possible. 

Symptoms.— Caseous  phthisis  does  not  conform  to  one  mode  of 
onset.  As  respects  the  initial  symptoms,  there  are  three  types— the 
chronic,  the  subacute,  and  the  acute,  or  phthisis  florida.  In  the  chronic 
form,  the  onset  is  so  gradual  that  the  first  symptoms  can  not  be  fixed 
on  with  certainty.  A  susceptibility  to  colds  has  been  observed,  and 
gradually  a  persistent  cough  and  expectoration  of  muco-pus  are  com- 
plained of.  Each  severe  cold  is  accompanied  by  chilliness,  some  fever, 
pains  in  the  chest,  loss  of  appetite,  and  a  troublesome  cough.  During- 
an  attack  of  this  kind  there  may  be  bloody  expectoration,  or  a  mouth- 
ful or  two  of  coagulated  blood  may  be  brought  up,  or  there  may  be  a 
smart  pulmonary  hfemorrhage.  After  such  an  attack  it  is  observed  that 
the  "  cold"  does  not  get  well  ;  that  the  cough  and  expectoration  per^ 
23 


354: 


DISEASES   OF  THE  RESPIRATORY  ORGANS. 


sist,  that  there  are  a  daily  morning  chilliness,  an  evening  fever,  and  a 
sweat  some  time  during  the  night.  A  considerable  loss  of  flesh  is  now 
observed,  and  there  are  great  weakness  and  a  feeling  of  exhaustion  on 
slight  exertion  ;  the  appetite  is  poor,  digestion  is  feeble,  and,  if  a  fe- 
male, the  catamenia  are  becoming  scanty.  In  the  subacute  variety  the 
onset  is  not  so  gradual.  There  is  a  history  of  a  severe  cold,  with  pain 
in  the  chest,  a  considerable  fever,  a  troublesome  cough,  and  abundant 
expectoration.  The  attack  is  severe  enough  to  require  confinement  to 
bed  for  a  few  days,  and,  although  after  a  week  or  two  some  improve- 
ment slowly  takes  place,  and  the  patient  gets  about  again,  the  symptoms 
continue  ;  there  are  fever,  some  sweating  at  night,  a  persistent  cough, 


Day   17   18   19    20  21    22  23  24  25  26  27  28  29  30  3!  32  33 

106" 

in/D -s f 

^                                                                      \                  -        \                                      -       ^       I 

-Mvr \ -\-A \--k K-K—P^-,'- 

l       *-        K   ^   '-i^M     S  *-  M   ^^ 

'°2        A       K      ^  ^-i   t  ^  i  ¥   ^  /  V  H 

H        ^K_iil^^^t;li^t 

\>  \/    i/    »         -                 V 

im^                 ,    ^  ^ 

fOO             ^J                                     ^ 

y 

98'     _         _    _         _-_ _ 

Fig.  28. — Temperatui-e  of  Catarrhal  Pneumonia  becoming  caseous — Phthisis  Florida. 

pains  in  the  chest,  expectoration  at  first  of  frothy  mucus,  then  of  muco- 
pus  ;  emaciation  goes  on  and  the  strength  does  not  improve  ;  the 
appetite  is  indifferent.  In  a  portion  of  these  cases,  after  the  catarrhal 
products  have  become  caseous,  there  is  a  period  of  comparative  repose, 
in  which  all  the  symptoms  appear  less  severe.  The  cough  lessens,  the 
fever  declines,  the  appetite  improves,  and  a  notable  gain  in  flesh  may 
ensue.  Under  such  circumstances  the  patient,  and  physician  also,  may 
feel  greatly  encouraged  ;  but  none  of  the  physical  signs  indicating 
consolidation  of  the  caseous  area  change  their  significance,  and  the 
symptoms  of  imiDrovement  prove  delusive.  Presently  the  process  of 
softening  begins  (after  some  weeks,  even  many  months),  and  with  the 
softening,  destruction  of  the  pulmonary  parenchyma  and  the  forma- 
tion of  cavities.  Caseous  phthisis  may  come  on  in  an  apparently 
healthy  individual — it  may  be  in  a  robust  subject,  of  a  full  habit.  In 
a  few  months  a  marked  decline  in  strength,  flesh,  and  activity  has  oc- 
curred— all  dating  from  the  time  of  the  acute  cold  (catarrhal  pneu- 
monia), since  which  the  symptoms  of  pulmonary  trouble  have  persisted. 
In  the  acute  variety  or  phthisis  florida,  the  whole  course  of  the  disease 
is  run  in  a  few  weeks.  It  begins  as  a  catarrhal  pneumonia,  involving 
almost  the  whole  of  one  or  parts  of  two  lungs.  It  commences  rather 
abruptly,  with  chilliness,  fever,  cough,  pain  in  the  chest,  and  rapid  loss 


PHTHISIS   PULMONALIS.  355 

of  strength.  The  temperature  runs  very  high  during  the  exacerbations, 
to  104°,  105°  Fahr.,  or  even  higher,  and  there  are  considerable  remis- 
sions and  profuse  and  exhausting  sweats.  Owing  to  the  sudden  ob- 
struction of  so  much  of  the  breathing-space,  there  is  marked  dyspnoea. 
The  cough  is  very  troublesome,  preventing  sleep,  and  the  expectoratioo 
is  profuse,  purulent  in  character,  and  often  streaked  with  blood  or 
bloody,  but  has  not  the  rusty  appearance  of  the  sputa  of  croupous 
pneumonia.  The  body  emaciates  rapidily,  the  strength  is  soon  utterly 
gone,  and  the  appetite  is  entirely  absent.  The  symptoms  increase  in 
intensity,  so  that  in  the  course  of  a  few  weeks  or  months  the  case  ter- 
minates in  death.  Rarely  a  remission  in  all  the  symptoms  takes  place, 
an  improvement  in  the  local  and  general  condition  follows,  and  there- 
after the  case  pursues  a  more  chronic  form.  In  these  cases  of  2yhthisis 
florida,  a  large  part  of  on^  lung  or  parts  of  the  two  lungs  are  occu- 
pied with  the  catarrhal  pneumonia,  and  the  products  of  the  inflamma- 
tion undergo  caseous  degeneration,  so  that  after  death  a  lung  may  be 
a  mass  of  cheesy  deposit. 

2.   TUBEROULAK    PHTHISIS. 

Definition. — ^Tubercular  phthisis  is  that  form  of  pulmonary  con- 
sumption characterized  by  the  deposit  of  tubercle  ;  by  the  changes 
due  to  such  deposit,  its  softening  and  extrusion,  and  the  less  or  greater 
destruction  of  the  proper  tissue  of  the  lungs  consequent  on  these  pro- 
cesses. Tubercular  deposit  in  these  cases,  if  not  limited  to,  is  chiefly 
in  the  lung,  and  the  disease  of  the  lung-tissue  quite  overshadows  that 
of  any  other  organ.  Acute  tuberculosis  is  a  general  deposit  of  the 
miliary  tubercle,  accompanied  by  symptoms  of  universal  disturbance 
of  the  functions  of  the  body.  As  it  is  a  general  and  not  a  local  dis- 
ease, it  is  more  appropriately  considered  with  constitutional  diseases. 

Etiology. — That  tubercular  consumption  is  an  inherited  malady, 
is  held  by  most  authorities.  Although,  by  some  leaders  of  modern 
medical  thought,  a  certain  peculiar  "  vulnerability  of  constitution  "  is 
transmitted  and  not  the  disposition  to  phthisis,  the  fact  is  undoubted 
that,  when  tuberculosis  exists  in  a  family  line,  it  appears  from  one 
generation  to  anothei-.  This  disposition  to  consumption  is  closely 
associated  with  scrofula  or  struma.  In  early  life  struma  manifests 
itself  by  glandular  enlargements,  a  tendency  to  protracted  suppuration, 
and  the  development,  under  iri'itative  conditions,  of  tubercle.  After 
puberty,  the  tendency  of  the  strumous  constitution  is  to  tubercular 
deposit  in  the  lungs.  One  of  the  factors  in  determining  tuberculosis 
of  the  lungs  is  a  badly  formed  thorax.  The  position  at  the  apex,  the 
favorite  seat  of  tubercular  deposit,  may  be  due  to  the  imperfect  respi- 
ration at  this  point,  owing  to  its  position  and  conformation.  All  the 
conditions  which  dej)ress   the   bodily  forces  favor  the   growth  and 


356 


DISEASES   OF   THE   RESPIRATORY   ORGANS. 


deposit  of  tubercle.  Confined  and  foul  air,  excess  of  humidity,  and 
rapid  variations  of  temperature,  are  very  influential  elements  in  the 
sum  of  causes.  Living  and  sleeping  in  badly  ventilated  apartments 
impair  the  quality  of  the  blood,  and  invite  disease  to  the  lungs.  A 
direct  relation  has  been  ascertained  to  exist  between  the  amount  of 
consumption  in  a  given  locality  and  the  humidity  of  the  air.  Bow- 
ditch  first  ascertained  this  for  Massachusetts,  and  the  same  fact  was 
also  shown  in  England.  Variability  of  climate  and  rapid  and  extreme 
atmosphei'ical  vicissitudes  have  a  most  injurious  effect  on  those  hav- 
ing a  tubercular  diathesis.  Elevation  and  dryness  are  as  conspicu- 
ously beneficial  as  the  opposite  conditions  are  hurtful  to  those  having 
a  phthisical  tendency.*     The  absence  of  sunlight,  by  contributing  to 


Fig.  29. — Miliary  Tuberculosis.    (Thierfelder.) 

anaemia,  also  favors  the  development  of  tuberculosis.  Improper  and 
insufficient  food  is  an  influential  factor.  The  repugnance  to  fat,  which 
is  so  often  manifested  by  the  phthisical,  is  unfortunate,  since  it  is  so 
necessary  as  a  force-furnishing  food.  "  Is  phthisis  communicable  ?  "  is 
a  question  which  can  not  now  be  answered,  but  which  seems  supported 
by  many  affirmative  examples.     The  first  experiments  with  the  inocu- 

*  See  Lombard,  "Traitc  de  Climatologie  Medicale,"  etc.,  tome  iv,  Paris,  Baillifere  et 
fil3,  1880,  p.  404,  dseq. 


PHTHISIS  PULMONALIS.  357 

lation  of  tubercle,  by  Villemin,  apparently  proved  its  specificity,  but 
subsequent  researches  have  shown  that  it  has  no  more  infective  prop- 
erty than  other  animal  matter.  The  frequent  examples  of  apparent 
communication  of  the  disease  between  husband  and  wife,  w^hen  an  he- 
reditary tendency  had  been  proved  not  to  exist,  have  awakened  strong 
suspicions  of  the  possibility  of  communication.  That  tuberculosis  may 
result  from  other  thoracic  diseases  is  now  a  well-established  fact  ;  it  is 
secondary  to  catarrhal  (caseous)  pneumonia,  to  chronic  bronchitis, 
hsemoptysis,  and  pleurisy. 

Pathological  Anatomy. — The  miliary  tubercle  is  a  grayish-white, 
translucent,  and  semi-solid  granulation,  about  the  size  of  a  millet-seed, 
composed  of  a  reticulum,  with  cells,  giant-cells,  and  nuclei,  the  cells 
resembling  white-blood  corpuscles  except  that  they  are  smaller,  and 
the  giant-cells  having  many  nuclei.  The  reticulum  is  an  extremely 
delicate  network,  inclosing  the  cells  in  its  meshes,  the  giant-cells 
being  placed  nearly  at  the  center  of  the  granulation.  It  is  this  gray 
miliary  tubercle  which  is  deposited  in  the  lungs,  and  constitutes  pul- 
monary tuberculosis.  According  to  Rindfleisch,  tubercle  takes  its 
origin  from  the  connective-tissue  cells  of  the  blood  and  lymph  vessels, 
and  the  first  deposits  occur  at  the  point  where  the  bronchioles  unite 
wath  the  acini.  (A  group  of  acini  communicating  with  a  bronchus  is 
a  lobule.)  A  whitish  nodule — a  tubercle  granulation — is  thus  formed 
around  the  termination  of  the  bronchiole  in  the  acini,  in  the  angle  at 
their  point  of  junction,  the  deposit  being  in  the  connective  tissue. 
The  nutrient  vessels  are  included  in  the  granulation,  and  their  adven- 
titia  become  swollen  and  infiltrated.  It  is  this  development  of  tubercle 
in  the  connective-tissue  cells  of  the  adventitia  that  weakens  the  vessel, 
and  which  may  finally  cause  a  rupture  and  hasmorrhage.  So  many 
vessels  at  the  apex  are  occluded  by  the  mass  of  the  deposits,  that  the 
pressure  in  the  remaining  vessels  is  much  increased.  When  the  walls 
of  the  vessels  are  infiltrated,  rupture  occurs  the  earlier  by  reason  of 
th^  increased  pressure  from  the  cause  just  named.  Tubercular  deposi- 
tion also  takes  place  abundantly  in  the  bronchioles,  not  only  those  in 
immediate  relation  to  the  lobules,  but  for  some  distance  beyond.  The 
lymphatics  distributed  to  the  mucous  membrane  are  infiltrated,  and 
next  those  of  the  peribronchial  space,  so  that  all  around  the  alveoli 
and  bronchioles  are  thickly  placed  masses  of  tubercle  granulations. 
The  intervening  connective  tissue  is  also  densely  infiltrated.  With 
the  deposit  of  tubercle,  there  are  associated  the  results  of  inflammation 
excited  by  the  presence  of  these  granulations.  According  to  Rind- 
fleisch, a  desquamative  pneumonia  plays  an  important  part  in  the  subse- 
quent changes.  The  cheesy  transformation  of  the  products  of  catarrhal 
pneumonia,  atelectasis,  bronchial  dilatation,  assist  materially  in  enlarg- 
ing the  area  of  structural  changes.  The  masses  of  miliary  tubercle,  in 
a  variable  period  after  their  deposition,  and  often  within  a  few  weeks. 


358  DISEASES   OF   THE   RESPIRATORY   ORGANS. 

undergo  a  cheesy  transformation,  by  Tvhicli  they  are  brought  into  close 
resemblance  to  the  cheesy  products  of  caseous  pnuemonia.  It  is  a 
process  of  fatty  degeneration,  beginning  in  the  central  portion  of  each 
nodule.  In  acute  tuberculosis,  to  be  studied  hereafter,  the  gray  granu- 
lation is  disseminated  throughout  both  lungs.  In  the  pulmonary  tuber- 
culosis, the  deposits  occur  chiefly  in  the  superior  lobes,  and  are  often 
limited  to'the  apex,  but  are  A^ery  rarely  indeed  confined  to  one  lung,  and, 
when  this  is  the  case,  the  left  is  more  often  attacked  than  the  right. 
When  the  process  of  cheesy  transformation  is  completed,  the  resulting 
mass  is  opaque,  yellowish,  and  has  the  friability  of  cheese.  The  infiltra- 
tion of  all  the  parts,  ultimately,  of  which  the  parenchyma  of  the  lungs  is 
composed,  the  closure  of  the  vessels  and  entire  arrest  of  the  nutritive 
supply,  and  the  compression  exerted  by  the  contracting  connective  tis- 
sue, necessarily  cause  a  necrosis  of  the  pulmonary  elements.  When 
the  stage  of  softening  comes  on,  the  products,  although  having  a  puri- 
form  appearance,  are  not  purulent.  Inflammation  and  suppuration  are 
excited  in  the  tissues,  with  the  necessary  result  of  disintegration.  On 
the  surface  of  the  mucous  membrane  the  destruction  of  the  tissue  in 
and  about  the  site  of  the  tubercle  granulations  is  an  ulceration  ;  in  the 
mass  of  disease  in  the  body  of  the  lung  the  destruction  of  tissue  pro- 
duces a  cavity.  The  fluid  matter  resulting  from  the  softening  of  the 
yellow  tubercle  is  homogeneous,  of  the  consistence  of  cream,  and  hav- 
ing a  greenish-yellow  or  grayish  color.  Mixed  with  it  are  necrosed 
pulmonary  elements,  solid  particles  of  a  yellowish  color,  and  the  whole 
is  contained  in  a  small  cavity,  surrounded  by  masses  of  cheesy  tubercle. 
The  softening  proceeds  from  the  center  to  the  periphery,  and  in  its 
progress  the  pulmonary  elements  are  disintegrated  with  it.  When 
discharge  of  a  cavern  takes  place  by  the  ulceration  opening  a  bronchus, 
or,  according  to  Rindfleisch,  by  the  tubercular  ulceration  of  a  bronchus, 
the  elastic  fibrous  tissue  may  be  recognized  in  the  sputa.  Large  cav- 
erns are  formed  by  the  breaking  down  of  the  intervening  septa  and 
the  coalescence  of  smaller  ones.  The  increase  in  the  area  of  destructive 
ulceration  is  greatly  promoted  by  the  attacks  of  catarrhal  (desquama- 
tive) pneumonia,  which  induce  softening  and  dilatation  of  the  bronchi, 
collapse  of  lobules  (atelectasis),  catarrhal  products,  that  fill  the  alveoli 
and  bronchi,  and  there  caseate.  Cavities  are  produced  under  these 
circumstances  by  the  softening  and  extrusion  of  the  caseous  masses  as 
described  under  the  head  of  caseous  phthisis.  In  this  case  the  tubercle 
granulation  is  the  exciting  cause  of  the  catarrhal  pneumonia  ;  in  the 
former  the  products  of  catan-hal  pneumonia  undergo  the  caseous  change 
in  consequence  of  a  peculiar  "invulnerability"  of  the  constitution, 
without  which  the  catan-hal  products  would  pass  through  the  ordinary 
changes.  Dilatation  of  the  bronchi,  or  bronchiectasis,  plays  an  impor- 
tant part.  In  catarrhal  pneumonia,  the  walls  of  the  bronchi  yield  in 
consequence  of  an  extension  of  the  inflammatory  process  to  them,  and. 


PHTHISIS  PULMONALIS.  359 

as  the  existence  of  dyspnoea  renders  greater  inspiratory  efforts  neces- 
sary, and  as  the  area  for  the  admission  of  air  is  much  reduced,  obvi- 
ously the  intcrbronchial  pressure  is  raised,  so  that  greater  force  is  ex- 
erted against  the  weakened  tubes.  According  to  Rindfleisch,  the  walls 
of  some  cavities  are  in  j^art  formed  by  dilated  bronchi.  Cavities,  still 
extending,  have  no  proper  boundary,  and  are  surrounded  by  tubercle 
and  caseous  masses  undergoing  softening,  and  by  detritus  of  the  lung- 
tissue.  Others  are  lined  by  a  connective-tissue  membrane,  which  con- 
tinuously pours  out  a  puriform  matter  of  a  greenish-yellow,  often  hav- 
ing a  foul  odor  by  reason  of  decomjjosition  from  the  presence  of  air. 
When  the  cavity  is  recently  formed,  not  only  are  its  sides  ragged  and 
uneven,  but  large  bands  traverse  it,  remains  of  pulmonary  tissue  not 
destroyed.  Other  organs  besides  the  lungs  are  affected.  The  jo/ewroj 
is  usually  the  seat  of  a  chronic  inflammation  ;  it  may  take  the  form  of 
a  dry  pleurisy,  and  close  adhesions  form  universally,  so  that  the  cavity 
is  obliterated  ;  or  the  adhesions  may  be  local  and  partial  when  they  are 
chiefly  at  the  apex  ;  or  a  neo-membrane  is  formed,  and  both  the  pleura 
and  the  new  membrane  may  become  tuberculous.  Extensive  effusion 
may  be  formed  in  consequence  of  the  rupture  of  a  cavity  and  the  escape 
of  its  contents,  when  a  pyopneumothorax  results.  A  cavity  perforated 
and  firm  adhesions  having  formed,  the  pleura  may  ulcerate  and  dis- 
charge take  place  through  the  thoracic  parietes,  a  fistula  remaining.  The 
hronchial  glands  enlarge  by  hyperplasia  of  their  contents,  which  un- 
dergo caseation.  They  may  be  dry  and  cheesy,  or  suppurate  and  dis- 
charge, the  pus  finding  an  exit  by  the  trachea,  or  by  a  bronchus,  or  by 
the  (Esophagus.  In  infants  and  children,  enlarged  bronchial  glands 
may  compress  the  trachea  or  bronchi,  or  the  pneumogastric,  and  thus 
give  rise  to  suffocative  attacks.  It  may  be  well  to  mention  that  the 
late  Dr.  Fuller,  of  London,  had  secondary  pyaemic  abscesses  of  the 
brain,  fi-om  suppurating  bronchial  glands.  The  larynx  always  suffers 
from  some  morbid  change  in  pulmonary  tuberculosis.  From  simple  hy- 
persemia  up  to  extensive  tubercular  ulcerations,  destroying  the  epiglottis, 
vocal  cords,  etc.,  there  are  numerous  gradations  in  the  severity  of  the 
lesions.  Tubercular  ulcerations  also  occur  in  the  oesophagus,  stomach, 
and  intestines,  but  the  point  of  greatest  development  of  the  ulceration 
is  the  lower  part  of  the  ilium  and  the  large  intestine.  The  tubercular 
troubles  of  the  intestinal  canal  are  found  in  two  stages  :  the  initial  de- 
posit, and  the  softening  and  destruction  of  tissue  or  ulceration.  The 
peritoneum  is  granulated,  and  chronic  lesions  of  the  peritoneum  coin- 
cide with  the  formation  of  ulcers  in  the  intestine.  The  liver  is  usually 
in  an  advanced  stage  of  fatty  degeneration,  but  in  rare  instances  the 
change  is  that  of  amyloid  disease.  In  the  kidney,  the  amyloid  degen- 
eration is  more  common  than  the  fatty.  Tubercular  ulcerations  are 
often  found  all  along  the  urinary  tract. 

Symptoms. — There  is  a  peculiar  type  of  constitution,  as  a  rule,  asso- 


360  DISEASES   OF  THE  RESPIRATORY  ORGANS. 

ciated  with  tuberculous  phthisis,  which,  being  present,  may  serve  to 
excite  suspicions,  at  least,  in  obscure  and  doubtful  cases.  These  pecu- 
liarities are  observed  in  growing  youths  and  young  men,  and  may  be 
described  as  follows  :  They  are  tall  and  rather  thin  ;  the  neck  is  long 
and  small ;  the  thorax  flat,  narrow,  and  having  but  little  expansile 
mobility  ;  the  muscles,  especially  of  the  chest  and  neck,  are  thin  and 
poorly  developed  ;  the  intercostal  spaces  are  wide  ;  the  hair  is  fine,  the 
eyelashes  long  ;  the  eyes  are  large  and  bright,  the  sclerotic  glistening  ; 
the  skin  is  transparent  and  thin,  the  color  quickly  changes,  and  the 
veins  are  blue  and  distinct ;  the  fingers  are  long  and  tapering,  but  their 
extremities  are  incurved  or  club-shaped.  These  subjects  possess  certain 
moral  and  mental  characteristics  also  :  they  are  impressionable,  the  dis- 
position is  variable  ;  they  are  fond  of  activity,  but  fatigue  easily  ;  oth- 
ers are  more  phlegmatic,  speak  slowly,  and  differ  in  complexion,  being 
dark,  with  thick,  muddy  skins.  When  these  peculiarities  of  constitu- 
tion coexist,  with  an  hereditary  tendency  to  phthisis,  they  possess  a 
high  degree  of  significance.  In  such  subjects,  a  cough,  losing  flesh  and 
strength,  with  a  red  line  along  the  margin  of  the  gum,  are  strongly  in- 
dicative of  the  onset  of  phthisis,  even  when  the  physical  signs  may  not 
be  jjositive.  A  large  proportion  of  the  cases  begin  by  loss  of  appetite, 
indigestion,  decline  in  weight,  without  cough  or  any  symptom  referable 
to  the  lung.  In  women  these  symptoms  are  accompanied  by  disorders 
of  menstruation.  Again,  an  attack  of  haemoptysis  may  be  the  first 
.symptom.  Most  usually,  the  onset  of  the  disease  is  characterized  by  a 
short,  dry  cough,  which  is  rather  more  troublesome  at  night,  preventing 
sleep,  some  shortness  of  breath,  pains  in  the  chest,  either  wandering  or 
fixed  in  the  position  of  an  intercostal  nerve,  or  a  sharp  stitch  indica- 
tive of  pleurisy,  some  nocturnal  perspiration,  confined  at  first  to  the  neck 
-and  face,  decline  in  flesh  and  strength,  poor  appetite,  and  often,  more 
or  less  diarrhoea.  At  this  period,  too,  some  alteration  of  the  voice  is 
beginning  to  be  perceptible  and  bronchial  haemorrhage  occurs.  The 
progress  of  the  case  is  more  rapid  if  the  fever  now  appears.  This  may 
be  an  early  symptom  ;  it  may  be  postponed  until  the  period  of  soften- 
ing. The  action  of  the  heart  is  excitable  and  is  accelerated  by  slight 
causes  from  the  very  beginning,  and  the  pulse  is  soft  and  compressible, 
the  tension  of  the  vessels  being  low.  The  usual  type  of  fever  in  the 
beginning  is  the  quotidian.  There  is  a  daily  morning  remission,  an 
evening  exacerbation  terminating  in  a  sweat — the  so-called  hectic  fever. 
The  type  maybe  double  quotidian — two  paroxyms  of  fever  each  day — 
the  first  in  the  morning,  the  second  at  night.  The  range  of  temperature 
at  this  period  is  not  great,  the  minima  about  98°  Fahr.,  the  maxima 
102°  Fahr.  The  range  of  fever-heat  is  an  important  indication  of  the 
degree  in  which  the  morbid  processes  are  proceeding,  especially  those 
involving  the  lungs.  In  illustration  of  this  may  be  mentioned  phthisis 
Jlorida,  in  which  the  highest  temperature  of  this  disease  is  attained, 


PHTHISIS  PULMONALTS.  361 

because  of  the  immense  extent  of  the  caseous  deposits  undergoing  soft- 
ening and  extrusion.  As  the  case  proceeds,  all  of  the  rational  signs 
become  aggravated.  The  appetite  is  almost  gone  ;  in  severe  parox- 
ysms of  coughing,  in  the  last  straining  effort  to  dislodge  the  sputa, 
vomiting  is  excited,  an  accident  very  apt  to  occur  after  meals.  The 
diarrhoea  also  increases,  and  becomes  very  difficult  to  restrain.  The 
cough,  also,  grows  more  troublesome  and  painful,  the  expectoration 
more  abundant,  and  the  voice  harsh  and  husky.  Difficulty  of  swallow- 
ing comes  on  in  consequence  of  ulceration  of  the  epiglottis,  and  some- 
times the  attempts  at  swallowing  are  embarrassed  by  the  dropping  of 
particles  of  food  and  drink  into  the  glottis,  exciting  violent  suffocative 
attacks.  The  expectoration  assumes  a  different  character  at  various 
periods.  At  first  there  is  brought  up,  often  with  a  great  deal  of  effort, 
some  frothy  mucous  ;  after  a  time  the  sputa  become  purulent  or  muco- 
purulent, greenish  or  greenish-yellow  in  color,  without  air,  and  without 
viscidity,  unless  there  is  a  complication  of  pneumonia,  when  the  sputa 
will  have  a  grayish,  vitreous,  adhesive  charactei',  and  may  also  present 
a  slightly  rusty  aspect  from  the  admixture  of  blood,  or  may  be  simply 
streaked  with  blood.  These  adhesive  sputa  may  be  seen  in  large  muco- 
pus  expectorations,  as  isolated  particles.  The  sputa  often  have  a  stri- 
ated apj^earance,  at  one  time  supposed  to  have  much  significance,  but 
now  known  to  be  produced  by  the  diminution  of  the  cellular  elements 
and  the  presence  of  deformed  and  atrophied  cells  and  of  granules — 
changes  of  a  degenerative  kind  due  simply  to  retention  in  the  lung. 
The  most  significant  element  in  the  sputa  is  the  presence  of  elastic 
fibers  of  the  pulmonary  tissue.  These  bodies  are  most  easily  detected 
by  boiling  the  sputa  in  a  solution  of  caustic  soda  in  distilled  water 
(18 — 100)     according     to     the 

method  of  Fen  wick.*  The  next  ^'^."^t^f^j/'^^'^'i^^ 
change  in  the  sputa  is  the  char-  '^^  a""  c*  ^  ^  ^^  "  "  ^~ ' 
acteristic  impressed  on  them  by 
formation  in  small  cavities. 
They  then  consist  of  two  parts, 
a  frothy  muco-pus  from  the 
bronchi,  and  i^lated,  globular, 
compact  masses  without  air,  of     ".'S^^^^^  oC?^©^^o'^l^  "^-^  ^  "^  "^ 

a     greenish     or      grayish      color;     j„j.B,j._Fragineni,oi  Lung-Tissue  anu  ^^puta.    (.Beaie.; 

when  allowed  to  stand,  the  for- 
mer rises,  and  the  latter  sinks  to  the  bottom,  and,  if  put  in  water, 
sinks  quickly.  The  quantity  of  expectoration  varies  ;  in  the  begin- 
ning, because  then  it  is  derived  from  a  bronchial  catarrh  ;  afterward 
according  to  the  extent  of  the  cheesy  masses  undergoing  softening, 
the  size  of  the  resulting  cavities,  and  the  degree  in  which  bronchiec- 
tasis exists,     When  there  is  a  large  cavity,  quantities  of  little  more 

*  Op.  cit. 


362  DISEASES  OF  THE  KESPIRATORY  ORGANS. 

than  pus  are  expectorated.  When  the  patient  lies  in  a  position  to  per- 
mit accumulation  to  take  place,  the  expectoration  may  be  suspended, 
but,  when  the  position  is  changed,  the  pus  is  discharged  in  a  stream. 
Sputa  streaked  with  blood  and -rusty  sputa  have  already  been  alluded 
to  ;  but  expectoration  of  blood,  or  haemoptysis,  is  a  different  affair.  Ac- 
cording to  some,  phthisis  may  be  due  to  pulmonary  haemorrhage.  This 
notion  arose  from  the  clinical  fact  that  hsemoptysis  is  sometimes  the 
first  symptom  of  the  disease,  and  after  its  occurrence  there  is  an  imme- 
diate development  of  the  symptoms.  The  presence  of  blood-clot  is 
supposed  to  excite  an  irritation  which  has  for  its  ultimate  effect  the 
formation  of  tubercle.  The  most  generally  accepted  view  is,  that  haem- 
orrhage is  merely  a  symptom,  and  a  symptom  that  may  occur  at  any 
period.  If  we  accept  Rindfleisch's  demonstration,  that  the  formation 
of  tubercle  begins  in  the  connective-tissue  cells  of  the  adventitia  of  the 
vessels,  there  can  be  no  difficulty  in  comprehending  the  early  appear- 
ance of  haemorrhage  in  the  course  of  phthisis.  At  any  subsequent 
period,  the  extension  of  the  area  of  tubercle  formation  may  be  accom- 
panied by  haemorrhage.  Again,  haemorrhage,  and  often  of  large  size, 
may  be  due  to  the  erosion  of  an  unclosed  vessel  in  the  process  of  de- 
struction, ending  in  the  formation  of  a  cavity.  The  amount  of  blood 
'lost  varies  from  a  drachm  or  two  to  several  pounds.  The  blood  is 
bright  colored,  more  or  less  aerated,  and  comes  up  with  coughing  ;  but 
a  sudden  large  haemorrhage  may  pour  up  in  a  stream  and  be  ejected 
by  the  nose  as  well  as  mouth.  A  considerable  part  of  the  blood  may 
be  swallowed,  and  subsequently  vomited,  and,  as  it  is  then  acted  on  by 
the  gastric  juice,  presents  the  appearance  of  haematemesis  ;  but  the 
history  of  the  case,  the  rational  and  physical  signs  of  pulmonary  dis- 
ease and  the  absence  of  stomachal  disease  will  afford  the  data  for  a 
correct  diagnosis.  After  the  haemorrhage  has  taken  place,  and  the 
flow  is  arrested,  for  some  days  clots  of  small  size  and  blackish  in  color 
are  expectorated.  Occasionally  there  are  indications  of  the  approach 
of  a  haemorrhage,  the  significance  of  which  the  sufferers  from  them 
soon  learn  :  these  are  a  feeling  of  warmth  in  the  chest,  oppression 
of  breathing,  excited  action  of  the  heart,  and  a  rather  sweetish  and 
saltish  taste  in  the  mouth.  Usually,  nothing  in  the  nature  of  a  warn- 
ing of  the  approaching  haemorrhage  is  observed.  When  the  blood- 
taste  is  experienced,  the  mouth  should  be  examined,  for  the  gums  may 
be  the  source  of  the  haemorrhage.  Bleeding  from  the  posterior  nares 
may  also  be  confusing,  as  there  may  be  a  coincident  cough,  A  pul- 
monary haemorrhage  may  be  vicarious  of  the  menstrual  flow,  and  it 
may  be  determined  by  the  sudden  arrest  of  haemorrhoidal  bleeding. 


PHTHISIS  PULMOIS'ALIS.  363 


3.   FIBROID   PHTHISIS. 


Definition. — By  this  term  is  intended  a  form  of  consumjDtion  char- 
acterized by  hyperplasia  of  the  connective  tissue  of  the  lung  and 
atrophy  and  degeneration  of  its  pi'oper  structure.  In  this  resj^ect 
the  disease  corresponds  to  fibroid  liver,  fibroid  kidney,  etc. ;  but  the 
changes  do  not  begin  in  and  are  not  limited  to  the  connective  tissue. 
Bronchial  inflammation,  bronchiectasis,  and  bronchorrhoea,  are  among 
the  initial  changes,  the  jDulmonary  tissue  being  involved  subsequently. 
Ultimately  tubercular  deposits  occur,  and  the  lesions  produced  by 
these  are  added  to  those  already  existing  in  the  connective  tissue  and 
the  bronchi. 

Etiology. — Heredity  is  concerned  to  the  extent  that  the  type  of 
pulmonary  tissue  favorable  to  the  development  of  this  disease  is  trans- 
mitted. It  is  a  disease  of  mature  life,  after  the  middle  period,  and  is 
extremely  rare  before  thirty.  Next  to  heredity,  chronic  bronchitis  is 
the  most  influential  factor.  The  causes  of  chronic  bronchitis  are, 
therefore,  indirectly  the  causes  of  fibroid  phthisis. 

Pathological  Anatomy. — The  mucous  membrane  of  the  bronchi  is 
of  a  dark  red  in  the  more  recently  inflamed  parts,  of  a  slate-color  in 
the  older,  traversed  by  dilated  vessels,  its  glands  much  thickened  and 
elevated  above  the  general  surface.  The  sub-mucous  connective  tissue 
is  thickened,  the  muscular  layer  hypertrophied  at  first,  but  in  the  fur- 
ther progress  of  the  case  the  whole  tube  is  softened  and  dilated.  These 
dilatations  may  be  fusiform  or  sacculated.  The  latter  predominate, 
and  are  often  mistaken  for  cavities,  the  resemblance  being  the  more 
striking  if  the  dilatation  contains  an  accumulation  of  pus.  The  atro- 
phic changes  in  the  walls  of  the  bronchi  are  not  the  only  factors  con- 
cerned in  producing  dilatation.  The  force  of  the  expiration  in  cough- 
ing, the  contraction  of  the  adjacent  connective  tissue,  and  of  pleural 
adhesions,  are  also  concerned.  From  the  bronchi  the  inflammation 
slowly  extends  to  the  peribronchial,  perivascular,  and  interlobular  con- 
nective tissue.  An  hyperplasia  of  its  constituent  elements  takes  place, 
with  the  result  to  compress  the  vessels,  the  acini,  and  the  bronchioles. 
The  contraction  of  the  newly  formed  connective  tissue,  by  cutting  off 
the  blood-supply  and  encroaching  on  the  neighboring  parts  of  the  pul- 
monary tissue,  causes  an  atrophy.  Some  of  the  lobules  collapse  (ate- 
lectasis) ;  all  within  the  affected  area  contain  less  blood,  and  are  nar- 
rowed by  pressure.  The  collapsed  lobules  undergo  the  changes  already 
described.  In  the  progress  of  these  cases  catarrhal  pneumonia  ulti- 
mately plays  a  part ;  the  cheesy  masses  which  form  soften,  producing 
cavities.  The  protracted  suppuration  finally  invites  tubercular  deposit. 
So  that  the  cases  of  fibroid  phthisis,  although  differing  in  their  rate  of 
progress  and  in  the  greater  importance  of  the  sclerosis  to  the  other 
morbid  processes,  nevertheless  are  brought  into  close  relation  to  the 


364  DISEASES   OF   THE   KESPIRATORY   ORGAN'S. 

Other  forms  of  phthisis.  A  considerable  increase  of  the  connective 
tissue  of  the  lungs  occurs  in  chronic  tubercular  phthisis  ;  the  longer 
the  duration  of  the  disease,  in  fact,  the  greater  is  the  development 
attained  by  it.  The  walls  of  the  cavities  are  composed  of  a  dense  layer 
of  connective  tissue,  closely  united  to  the  same  tissue  of  the  lung.  In 
caseous  pneumonia  there  is  less  production  of  connective  tissue,  be- 
cause of  the  rapid  progress.  In  a  fibroid  lung  the  cavities  do  not 
attain  to  great  dimensions  ;  they  appear  as  interspaces  in  the  dense  tra- 
becule. When  these  intervening  portions  of  the  condensed  tissue  are 
divided,  they  are  ascertained  to  be  exceedingly  firm,  of  a  grayish  or 
slate  color,  containing  here  and  there  patches  of  brown  pigment,  and 
possess  but  little  vascularity.  The  early  compression  and  closure  of 
the  vessels  is  a  source  of  mischief  to  the  heart.  The  pulmonary  circu- 
lation being  obstructed  over  a  considerable  portion  of  the  lung,  the 
right  cavities  yield  to  the  increasing  pressure  and  dilate.  There  is, 
therefore,  a  stasis  of  the  venous  circulation  ;  the  liver  enlarges,  and 
ascites  is  produced  ;  the  kidneys  are  congested,  and  albumen  is  present 
in  the  mine.  These  complications  develop  toward  the  close  of  the 
malady. 

Symptoms. — Fibroid  phthisis  is  the  most  chronic  form  of  the  dis- 
ease ;  its  early  history  is  that  of  bronchial  catarrh  ;  and  it  is  not  until 
after  months,  even  years,  that,  extension  taking  place  to  the  lungs,  the 
progress  becomes  more  rapid.  For  months  there  is  merely  a  dry  cough, 
not  very  troublesome,  but  persistent.  The  expectoration  is  slight,  and 
is  nothing  but  mucus.  The  appetite  is  but  little  impaired,  and  the 
weight  and  strength  are  not  materially  reduced.  During  the  fall, 
winter,  and  spring  months  the  symptoms  increase  in  severity  ;  the 
cough  becomes  more  troublesome,  and  the  expectoration  more  abun- 
dant and  having  the  apjDearance  of  muco-pus.  The  symptoms  amelio- 
rate during  the  warm  months,  but  to  increase  again  with  the  changeable 
weather  of  "winter.  After  two  or  three  years  of  tliis  alternation,  there 
is  less  and  less  improvement  in  the  warm  months,  but  the  symptoms  of 
catarrh  continue  throughout  the  year.  Fever  comes  on  toward  even- 
ing, the  temperature  at  first  rising  to  100°  Fahr.  The  appetite  lessens, 
digestion  becomes  poor,  and  the  body-weight  progressively  declines. 
The  cough  is  harassing  and  prevents  sleep  ;  the  expectoration  be- 
comes more  profuse  and  entirely  purulent  ;  and  the  food  now  and 
then  comes  up  in  the  attempt  to  clear  the  larynx  and  fauces.  Some 
difficulty  of  breathing  is  experienced  ;  the  pulse  is  small  and  weak  ; 
the  skin  is  warm  toward  eA'ening,  while  slight  chilliness  is  felt  in  the 
morning,  and  sweating  occurs  during  the  night.  As  the  disease  ad- 
Tances,  the  temperature  reaches  101°  and  102°  in  the  evening,  but  it 
does  not  attain  to  the  altitude  reached  in  caseous  or  tubercular  phthisis. 
When  the  bronchi  dilate,  the  expectoration  becomes  profuse,  especially 
in  the  morning — a  cupful  or  more  may  be  brought  up  in  an  hour  or 


PHTHISIS  PULMONALIS. 


365 


two.  Fragments  of  fibrous  tissue  only  appear  in  it  when  cavities  are 
forming.  At  this  period  there  may  be  one  or  more  haemorrhages. 
Detritus  of  caseous  matter,  softening,  is  found  in  the  sputa  only  at 
this  later  period.  The  onset  of  tuberculosis  is  announced  by  increase 
of  dyspnoea,  rise  of  the  temperature,  alterations  in  the  voice,  and 
diarrhcea.  The  development  of  the  connective  tissue  and  the  com- 
pression of  the  vessels  lead  to  dilatation  of  the  right  cavities  of  the 
heart,  stasis  of  the  venous  system,  and  congestion  of  the  liver  and 
kidneys,  OEdema  of  the  feet  and  ankles  is  first  observed  ;  then  swell- 
ing of  the  legs  and  scrotum,  and  ascites  appear. 

Physical  Signs  of  Phthisis. — There  are  no  points  of  difference  as 
respects  the  physical  signs  of  phthisis  ;  hence  the  three  forms  may  be 
considered  together. 

The  abnormality  in  the  development  of  the  chest,  which  is  observed 
in  phthisical  subjects,  has  been  already  described.     In  the  movements 


Fig.  31.— Cavities;  one  partly  filled,  one  empty.    (Da  Costa.) 


of  the  ribs  during  expansion  in  inspiration,  deficiency  may  be  observed 
to  exist  on  the  diseased  side.  On  jpalpation,  increase  of  the  vocal  fre- 
mitus exists  over  consolidated  lung  and  over  cavities,  and  is  diminished 
or  wanting  over  effusion  in  the  pleural  cavity.  The  percussion-note 
has  great  variety.  All  shades  of  dullness  exist.  If  the  consolidation 
is  not  complete  and  some  air  still  enters  the  diseased  area,  the  note  is 
high-pitched,  but  with  a  somewhat  tympanitic  quality  ;  but  if  the  tissue 
is  entirely  without  air,  then  the  note  is  high-pitched  and  hard  in  qual- 
ity.    The  change  in  sonority  may  be  unilateral  or  double,  but  if  double 


366  DISEASES   OF   THE   RESPIRATORY  ORGANS. 

it  is  not  necessarily  symmetrical ;  it  may  be  infra-clavicular  on  one  side, 
infra-spinous  on  the  other.  The  dullness  may  be  due  to  various  causes 
— to  a  pleuritic  effusion,  to  pneumonic  consolidation,  or  to  a  tumor  or 
cyst.  The  extension  of  the  area  of  dullness  and  the  increase  in  hard- 
ness or  the  disappearance  of  the  tympanitic  quality  may  indicate  the 
increase  of  the  tubercular  or  caseous  deposition.  The  change  in  the 
sonority  of  the  lung  is  most  usually  at  the  apex,  but  it  may  be  iii  any 
situation.  During  the  process  of  softening  and  extrusion  there  is  no 
change  in  the  character  of  the  percussion-note  until  excavations  have 
formed ;  even  then  there  will  be  no  change,  unless  the  cavity  be  large 
and  near  the  surface.  The  percussion-note  may  present  a  nearly  nor- 
mal sonority  or  it  may  be  exaggerated  over  a  cavity  ;  it  may  have  a 
metallic  clang,  or  amphoric  quality  ;  it  may,  if  the  cavity  communi- 
cate with  a  bronchus,  have  the  cracked-pot  sound  {bruit  de  ^jot  fele). 
The  last  is  produced  by  strong  percussion^  the  vilbrations  occurring 
in  the  walls  of  the  cavity  and  in  the  column  of  air  in  the  bronchus, 
A  cavity  in  which  pus  has  accumulated  may  furnish  a  dull  sound  ; 
when  emptied,  the  amphoric  sound  will  return.  On  auscultation  the 
sounds  audible  will  present  great  variety.  The  vesicular  murmur  will 
be  unimpaired  in  those  parts  free  from  disease  ;  it  will  be  feeble  or  in- 
distinct if  many  bronchioles  are  obstructed  ;  it  will  be  rude  or  blow- 
ing if  the  bronchioles  are  narrowed  ;  inspiration  will  be  jerking  and 
expiration  prolonged  and  blowing  if  the  lung  has  lost  its  elasticity 
from  any  cause.  These  signs  are  much  less  significant  when  they 
occur  on  the  right  than  when  they  occur  on  the  left  side  (infra-clavicu- 
lar regions)  ;  in  the  former  situation,  they  are,  so  to  speak,  normal. 
Next  to  these  modifications  in  the  resj^iratory  murmurs  are  certain 
adventitious  sounds,  or  rales.  The  earliest  of  these  audible  in  the  in- 
fra-clavicular region  usually  is  a  fine,  dry,  crackling  sound  (sub -crepi- 
tant) appearing  at  the  end  of  inspiration,  and  sometimes  requiring  a 
deep  and  full  inspiration  to  develop  it.  This  rale  may  be  temporary, 
when  it  has  but  little  significance.  The  extension  of  the  inflammation 
to  the  larger  bronchi  induces  more  abundant  secretions,  and  the 
sub-crepitant  rale  becomes  a  distinctly  moist  sound,  and  audible  over 
a  larger  area,  and  coarser  sounds  also  moist — mucous  rales — are 
mixed  with  them.  With  these  rales  changes  in  the  respiratory  sounds 
take  place  :  inspiration  has  a  distinct  blowing  character  which  approxi- 
mates to  and  ultimately  does  become  bronchophonic — i.  e.,  the  sound 
of  the  movement  of  the  air  in  the  bronchial  tubes  and  of  the  voice  are 
communicated  to  the  ear  directly,  the  solidified  lung  acting  as  a  good 
conductor,  the  respiratory  or  vesicular  murmur  having  disappeared. 
These  are  the  sounds  of  consolidation,  and  of  softening  up  to  exti'u- 
sion.  When  cavities  form,  new  sounds  become  audible,  but  it  is  not 
always  easy  to  differentiate  between  bronchophony  and  amphoric  and 
cavernous  blowing,  the  signs  of  a  cavity.      Amphoric  blowing  and 


PHTHISIS  PULMONALIS.  367 

amphoric  voice  are  signs  of  a  cavity,  if  correctly  interpreted  ;  the  cav- 
ernous sounds  produced  in  a  large  cavity  with  thin  walls  are  more  sig- 
nificant. To  these  must  be  added  metallic  tinkling,  which  is  heard  in 
perfection  in  hydropneumothorax  and  under  similar  conditions  when 
the  cavity  is  large. 

Course,  Duration,  and  Terminafcion. — The  course  of  phthisis  is 
much  influenced  by  its  form.  Phthisis  florida,  or  acute  caseous 
phthisis,  runs  its  course  in  a  few  months,  and  not  often  with  intermis- 
sions, although  it  does  sometimes  intermit,  and  then  pursue  a  more 
chronic  course.  Its  usual  course  is  continuous — a  large  pai't  of  one  or 
of  both  lungs  may  be  occluded,  softening  occurs,  and  high  fever  with 
rapid  emaciation  soon  exhausts  the  powers  of  life.  The  usual  type  of 
caseous  phthisis  is  chronic  ;  there  are  repeated  bronchial  attacks  and 
gradually  increasing  consolidation,  the  interval  between  the  attacks 
being  characterized  by  varying  degrees  of  improvement,  but  with  a 
general  tendency  toward  decline.  In  many,  it  is  true,  under  judicious 
management,  the  catarrhal  process  is  arrested,  absorption  of  the  case- 
ous matter  takes  place  in  part,  the  rest  is  extruded,  with  more  or  less 
destruction  of  tissue  ;  cicatricial  tissue  supplies  the  place,  contraction 
ensues,  with  subsequent  retraction  of  the  chest-wall,  and  thus,  in  a 
limited  sense,  a  cure  is  effected.  In  other  cases  the  course  is  less 
marked  by  intermissions,  the  caseous  deposits  are  extensive,  and  there 
are  haemorrhages,  fever,  emaciation — the  symptoms  continuing  until 
death.  While  the  duration  of  the  former  type  may  be  two,  three,  and 
as  much  as  five  years,  or  during  the  ordinary  duration  of  life,  the  latter 
do  not  often  extend  two  years.  The  tuberculous  form,  also  pursues 
two  different  courses  :  one  chronic,  developing  slowly,  lasting  two 
years  or  more  ;  the  other  more  rapid,  the  whole  course  being  termi- 
nated within  a  year.  The  degree  in  which  broncho-pneumonia,  atelec- 
tasis, and  dilatation  of  the  bronchioles  occur,  the  extension  of  the  tuber- 
culosis to  the  larnyx  and  intestinal  canal,  and  the  number  and  severity 
of  the  haemorrhages,  are  important  factors  in  bringing  about  a  fatal  re- 
sult. So  long  as  the  tubercular  deposit  is  limited  to  the  lung,  is  slight 
in  extent,  there  is  a  jDossibility  of  recovery  by  extrusion,  shrinking  of 
the  lung,  and  retraction  of  the  ribs.  The  most  chronic  of  all  the 
forms  of  phthisis  is  the  fibroid.  The  course  of  this  may  occupy  sev- 
eral years,  indeed  an  ordinary  lifetime,  and  prove  fatal  at  last.  Of  all 
the  forms,  it  offers  the  best  prospect  of  a  cure,  if  the  changes  are  not 
too  extensive.  The  initial  period,  terminating  in  a  bronchiectasis,  may 
occupy  a  number  of  years  ;  at  first,  for  several  years,  there  is  winter 
cough  only,  the  warm  season  being  free,  or  nearly  so  ;  when  the  con- 
nective tissue  of  the  lung  is  invaded  the  progress  is  more  rapid,  for 
then  atelectasis  and  caseation  enter  as  elements  into  the  destructive 
changes.  Finally,  tuberculosis  is  ingrafted  into  the  morbid  process, 
which  then  advances  more  rapidly,  because  not  only  the  lungs,  but  the 


368  DISEASES   OF  THE    RESPIRATORY   ORGANS. 

larynx  and  intestinal  canal,  become  diseased  ;  the  range  of  temperature 
rises  higher,  and  emaciation  proceeds  at  an  accelerated  pace.  Phthisis 
is  the  great  enemy  of  the  human  race,  since  nearly  two  sevenths  of 
the  deaths  from  all  causes  are  due  to  this  disease.  But  a  few  years 
ago,  a  cure  of  any  case  was  regarded  as  hopeless  ;  but  within  recent 
times  the  improvements  in  our  knowledge  of  the  local  conditions  and 
in  the  means  of  treatment  have  led  to  better  results,  and  cures  are 
now  not  uncommon. 

Diagnosis. — The  diagnosis  of  phthisis  can  not  be  doubtful  after 
the  initial  period.  Incij)ient  phthisis  may  be  confounded  with  atonic 
dyspepsia.  A  cough  may  be  present  in  atonic  dyspepsia — the  so-called 
stomach-cough.  The  natural  differences  in  the  sonority  and  the  res- 
piration of  the  right  and  left  infra-clavicular  regions  may  materially 
contribute  to  the  error.  Attention  to  this,  and  to  the  fact  that  there 
is  no  point  of  irritation  about  the  air-passages  to  account  for  the  exist- 
ence of  a  cough,  will  settle  the  doubts.  More  frequently,  in  malarious 
regions,  is  hectic  fever  confounded  with  intermittent,  since  in  the  lat- 
ter there  is  usually  some  cough.  This  mistake  is  made  when  the  pul- 
monary disease  is  quite  advanced,  so  that  the  error  is  either  from 
ignorance  or  carelessness.  In  j)hthisis,  independently  of  the  physical 
signs,  the  fever  has  been  preceded  by  a  period  of  cough,  and  loss  of 
flesh  and  strength,  whereas  in  intermittent  these  symptoms  have  fol- 
lowed the  access  of  fever ;  in  phthisis  there  is  not,  in  intermittent 
there  is,  an  enlarged  spleen  ;  in  j)hthisis  the  hectic  is  not  arrested  by 
large  doses  of  quinine  ;  in  intermittent  the  fever  is  arrested  and  con- 
valescence is  at  once  established.  A  careful  study  of  the  physical 
signs  ought  at  once  decide  the  question.  Laryngeal  symptoms  are 
often  so  pronounced  in  the  beginning  as  to  obscure  the  pulmonary 
affection.  Indeed,  the  disease  in  the  lungs  is  referred  by  some  to  the 
larynx,  to  which  it  is  regarded  as  strictly  secondary.  This  error  has 
arisen  from  the  fact  that  considerable  infiltration  of  the  lung  may  exist 
without  seriously  imj3airing  its  sonority,  or  changing  or  modifying 
the  vesicular  murmur.  When  tubercular  deposits  occur  in  the  larynx, 
the  tone  and  quality  of  the  voice  are  quickly  affected,  so  that  the  lat- 
ter may  seem  to  be  the  only  seat  of  tubercular  deposit.  Although,  to 
determine  this  question,  time  may  be  necessary,  the  coexistence  of 
pulmonary  disease  ought  to  be  suspected,  because  of  the  relation 
known  to  obtain  between  them.  The  most  important  diagnostic  ques- 
tion relates  to  the  difference  between  caseous  and  tuberculous  phthisis. 
The  sections  devoted  to  these  two  forms  have  indicated  the  clinical 
and  pathological  differences  ;  nevertheless,  it  will  be  useful  to  state 
briefly  the  points  which  serve  to  distinguish  them.  Tubercular  phthisis 
is  distinctly  hereditary  ;  caseous  i^hthisis  is  not  hereditary,  but  occurs 
in  the  scrofulous.  Tubercular  phthisis  occurs  at  all  ages  ;  caseous, 
from  youth  to  middle  age.     Tubercular  phthisis  occurs  insidiously 


PHTHISIS  PULMOXALIS.  369 

with  catarrh  of  the  bronchi  and  larynx  ;  caseous  results  from  acute 
inflammations  of  the  bronchi  and  lungs.  Tubercular  phthisis  is  more 
often  than  the  caseous  a  cause  of  pulmonary  haemorrhage.  In  tuber- 
cular phthisis  the  lesions  are  apt  to  be  on  both  sides  ;  in  caseous,  on 
one  side.  In  tuberculosis  of  the  lung,  tubercle  may  be  widely  dissem- 
inated without  any  striking  physical  signs  ;  in  caseous  phthisis  the 
caseous  deposits  produce  very  pronounced  physical  symptoms.  The 
laryngeal  symptoms  are  much  more  common  in  tubercular  than  in 
caseous  phthisis.  The  progress  in  tuberculous  phthisis  is  moi-e  rapid 
and  the  mortality  greater  than  in  caseous.  Fibroid  phthisis  is  distin- 
guished from  the  other  forms  by  its  slow  progress,  by  the  long  period 
of  bronchial  troubles  before  the  pulmonary  lesions  begin,  by  the  merely 
purulent  expectoration,  without  fibrous  tissue,  until  late  in  the  prog- 
ress of  the  case,  and  by  bronchial  dilatation  long  before  the  cavities 
by  excavation  form. 

Treatment. — When  a  phthisical  tendency  exists,  prophylaxis  be- 
comes highly  important.  Although  not  often  consulted,  physicians 
should  discourage,  directly  and  indirectly,  the  marriage  of  the  phthisi- 
cal. Children  inheriting  the  dyscrasia  should  have  a  careful  physical 
training,  substantial  food,  warm  clothing,  and  exercise  in  the  open  air 
without  exposure.  They  should  be  guarded  against  attacks  of  bron- 
chial catarrh,  of  measles,  and  whooping-cough,  for  in  these  diseases 
the  seeds  are  sown  of  future  mischief.  As  humidity  is  such  an  im- 
portant factor  in  the  etiology  of  phthisis,  and  as  dryness  and  elevation 
are  climatic  conditions  of  the  greatest  utility,  if  possible,  the  growing 
child  should  be  separated  from  the  one  and  placed  in  the  other.  Sing- 
ing should  be  encouraged,  since  that  tends  directly  to  improve  the  nu- 
trition of  the  lung,  especially  of  the  apex.  Cold  bathing  should  be 
practiced  every  morning  to  diminish  the  susceptibility  to  cold.  Ca- 
tarrhal attacks  occurring  should  receive  prompt  attention,  and  any 
lingering  remnant  of  local  morbid  action  should  be  carefully  removed. 
The  tendency  to  such  attacks  and  the  removal  of  the  effects  produced 
by  them  are  equally  controlled  by  the  iodides  (iodide  of  iron)  and  cod- 
liver  oil.  As  phthisis  is  preeminently  a  wasting  disease,  it  is  highly 
important  to  put  the  organs  concerned  in  nutrition  into  the  highest 
state  of  efficiency.  In  tubercular  and  fibroid  phthisis,  among  the  ear- 
liest symptoms  are  stomach  disorders,  poor  appetite,  atonic  or  acid 
indigestion,  and  especially  repugnance  to  the  fatty  elements  of  food. 
The  mineral  acids,  with  a  bitter,  such  as  tincture  of  nux  vomica,  are 
especially  serviceable.  If  there  be  acid  eructations,  pyrosis,  and  heart- 
burn, the  mineral  acids,  especially  nitro-muriatic  (ten  to  fifteen  drops, 
well  diluted,  ter  in  die),  should  be  administered  before  meals  ;  but,  if 
the  condition  be  atonic  indigestion,  the  acid  should  be  given  after  meals. 
The  nux-vomica  tincture  should  be  given  before  meals — fifteen  drops 
in  water.  The  aliment  should  consist  of  easily  digested  articles  of  diet, 
24 


370  DISEASES  OF  THE  RESPIRATORY   ORGANS. 

and  the  stomach  should  not  be  overloaded  under  any  circumstances. 
It  should  never  he  forgotten  that  it  is  not  the  quantity  swallowed,  but 
digested  and  assimilated,  which  contributes  to  the  nourishment  of  the 
body.  There  are  certain  tonics  to  the  stomach  which  stimulate  the 
organ  to  more  efficient  work,  that  are  very  beneficial  in  promoting  the 
nutrition  of  the  body.  These  are,  besides  the  bitters  and  mineral  acids 
mentioned  above,  small  doses  of  arsenic  and  silver,  and  alcohol.  Arsenic 
is  deserving  of  special  commendation — in  incipient  phthisis,  to  promote 
the  appetite  and  favor  tissue-forming,  while  it  corrects  the  disordered 
state  of  the  stomach  mucous  membrane,  and  as  a  remedy  for  chronic 
tuberculosis  and  fibroid  lung.  The  author  must  impress  on  his  read- 
ers that  arsenic  must  be  given  in  small  doses,  as  it  is  to  be  continued 
for  a  long  period  (two  drops  three  times  a  day).  The  oxide  of  silver 
performs  much  the  same  office,  but  its  administration  must  be  brief, 
because  of  the  danger  of  coloring  the  skin  (Argyria).  Small  doses  of 
alcohol  after  meals  (half  an  ounce  for  adults)  are  highly  useful  to  pro- 
mote appetite  and  tissue-formation.  Physicians  should  not  encour- 
age the  dangerous  notion  that  whisky  is  antidotal  to  phthisis.  Fibroid 
phthisis  appears  to  be  produced  by  chronic  alcoholism.  Large  quan- 
tities of  alcoholic  fluids  impair  the  function  of  digestion,  and  lessen 
tissue-forming  ;  hence  the  amount  named — certainly  not  more  than 
twice  as  much — should  not  be  exceeded.  The  utility  of  cod-liver  oil 
in  incipient  phthisis  is  very  great.  As  the  power  to  digest  fats  is  con- 
fined within  narrow  limits,  and  as  the  ability  to  dispose  of  them  is 
relatively  less  in  consumption,  the  dose  of  cod-liver  oil  should  be  pre- 
scribed accordingly,  from  a  tea-  to  a  tablespoonful — a  teaspoonful  the 
usual  dose.  All  in  excess  of  the  capacity  to  digest  passes  unchanged, 
and  may  be  seen  floating  on  the  evacuations.  The  utility  of  cod-liver 
oil  consists  in  the  fact  that  it  is  a  fat,  having  a  special  digestibility, 
owing  to  its  containing  bile  elements,  and  is  therefore  peculiarly  fitted 
to  form  the  "molecular  basis  of  the  chyle."  It  is  not  useful  in  cases 
of  phthisis  florida,  or  in  caseous  phthisis  characterized  by  large  de- 
posits, high  fever,  and  diarrhoea.  In  incipient  phthisis  its  utility  is 
very  great,  and  only  less  so  in  chronic  tuberculosis  and  fibroid  phthisis. 
In  what  form  soever  it  may  be  given,  it  is  better  to  prescribe  it  with 
a  little  ether  (tti,  xx —  3  j),  because  of  the  action  of  the  ether  in  pro- 
moting the  flow  of  pancreatic  fluid — a  fact  demonstrated  by  Bernard, 
and  confirmed  by  clinical  observation.  Cod-liver  oil  may  be  given  in 
the  form  of  emulsion  with  the  lactophosphate  of  lime,  the  compound 
hypophosphites,  and  the  compound  phosphates.  The  simultaneous 
administration  of  these  remedies  is  good  practice,  and  the  emulsion 
may  be  allowed,  if  the  quality  of  the  cod-liver  oil  is  good,  but  it  should 
not  be  overlooked  that  an  inferior  oil  may  be  disguised  in  an  emulsion 
of  this  kind.  The  lactophosphate  of  lime,  if  well  prepared,  is  a  most 
valuable  agent  in  the  treatment  of  incipient  and  the  more  chronic 


PHTHISIS   PULMONAtlS.  371 

cases  of  phthisis.  The  hypophosphites,  although  not  deserving  the 
encomiums  first  pronounced  on  them  as  remedies  for  consumption,  are 
vahiable  agents  to  promote  the  constructive  metamorphosis.  It  is 
doubtful  whether  the  hypophosphites  present  any  advantages  over 
the  phosphates,  because  of  their  chemical  instability  and  rapid  conver- 
sion into  the  phosphates.  The  lactophosphate  of  lime  has  the  special 
advantage  that  it  is  a  soluble  combination  of  an  agent  very  important 
to  the  construction  of  tissue.  The  last-named  remedy  may  be  given 
in  a  dose  of  a  tea-  to  a  dessertspoonful  of  the  sirup  three  times  a  day, 
after  meals.  It  is  good  practice  to  give  it  with  cod-liver  oil,  but  not 
in  an  emulsion,  for  reasons  already  stated,  unless  the  emulsion  is  pre- 
pared extemporaneously  from  unquestionable  materials.  If  caseous  or 
tubercular  deposits  have  formed,  we  have  a  new  problem  for  solu- 
tion. Do  we  possess  means  to  procure  softening,  absorption,  and 
extrusion  ?  The  author  has  seen  such  good  results  from  the  salts 
of  ammonia  that  he  believes  this  question  may,  with  some  important 
limitations,  be  answered  in  the  affirmative.  A  combination  of  the 
carbonate  and  iodide  of  ammonium  seems  to  procure  the  best  results 
— five  to  ten  grains  of  the  carbonate  and  the  same  quantity  of  the 
iodide  in  solution  in  water.  If  the  stomach  is  irritable,  the  dose 
must  be  small.  As  a  rule,  five  grains  of  each  remedy  four  times  a 
day  is  better  than  a  larger  dose  less  often.  This  combination  should 
be  resorted  to  when  the  vesicular  murmur  is  assuming  a  blowing 
character  and  the  sonority  is  diminishing,  and  it  should  be  continued 
for  several  weeks,  for  months,  if  improvement  is  manifest  under  its 
use. 

Some  of  the  chief  symptoms  require  remedies  to  restrain  them  in 
proper  limits,  as  cough,  fever,  sweats,  haemorrhage,  laryngeal  symp- 
toms, and  diarrhoea.  These  we  consider  in  turn.  If  cough  is  very  dis- 
tressing, some  relief  becomes  necessary,  and  the  constant  temptation  is 
to  resort  to  anodynes.  Gargling  the  throat  with  a  solution  of  bromide 
of  potassium,  applying  a  mixture  of  chloral  and  camphor  by  means  of 
a  camel's-hair  brush  to  the  fauces,  the  atomization  of  a  solution  of 
morphia,  are  expedients  temporarily  beneficial.  Fothergill's  prescrip- 
tion of  hydrobromic  acid  (diluted)  and  spirit  of  chloroform  sometimes 
acts  well,  but  is  often  inefficient.  Of  the  principles  contained  in  opium, 
codeia  is  the  least  objectionable  ;  it  causes  less  disturbance  of  the  diges- 
tive organs,  and  has  more  effect  on  cough.  A  combination  of  codeia, 
atropia,  and  strychnia  is  highly  efficient  as  a  remedy  for  cough,  for 
night-sweats,  and  reflex  vomiting.  Picrotoxine  allays  the  vomiting 
which  accompanies  the  cough  almost  as  efficiently  as  strychnia,  and 
has  at  the  same  time  decided  anhydrotic  effect.  A  resolute  patient 
may  suppress  cough  to  a  very  great  extent  by  an  effort  of  the  will. 
The  irritable  feeling  in  the  fauces  may  be  allayed  by  a  bit  of  gum- 
arabic  or  candy,  or  a  troche.     The  officinal  troche  of  liquorice  and 


372  DISEASES   OF   THE   RESPIRATORY   ORGANS. 

opium,  or  of  morpliia  and  ipecac,*  may  be  employed  in  this  way  ad- 
Tantageouslv.  In  the  treatment  of  the  fever  of  phthisis,  the  first  and 
most  important  remedy  is  rest.  Under  a  mistaken  notion  of  the  value 
of  exercise,  phthisical  subjects,  haying  a  high  fever,  attempt  an  active 
out-door  life.  A  very  considerable  increase  of  the  normal  increment 
of  fever  takes  place  when  exercise  is  attempted,  and  a  corresponding 
diminution  when  repose  is  enforced.  As  a  high  range  of  temperature 
is  most  injurious,  it  is  necessary  to  reduce  it  as  much  as  possible.  The 
most  effective  antipyretic  is  quinia,  but  to  reduce  the  fever  it  must  be 
given  in  sufficient  doses.  Twenty  grains  on  alternate  mornings  will 
usuallv  reduce  the  temperature  several  degrees  and  keep  it  within  the 
proper  limits.  Digitalis  is  too  nauseating  to  be  used  with  advantage, 
and  salicvlic  acid  is  more  unpleasant  in  all  respects  and  less  efficient 
than  quinia.  The  most  powerfxd  anhydrotic  which  we  possess  is  atro- 
pia.  For  an  adult  about  -gL.  of  a  grain  at  bed-hour  usually  suf- 
fices ;  but,  as  atropia  seems  to  have  a  special  action  on  the  lungs  in 
caseous  pneumonia,  it  is  better  to  give  it  in  smaller  doses  (ytw  ^^  roir 
grain)  three  times  a  day.  Under  its  use  there  is  often  a  remarkable 
improvement  in  the  condition  of  the  patient,  not  due  solely  to  the 
arrest  of  the  night-sweats,  but  to  some  special  property.  The  com- 
bination before  referred  to  is  a  suitable  form  for  the  administration  of 
atropia — with  codeia  and  picrotoxine.  Sometimes  remarkably  good 
results  follow  the  use  of  pilocarpine,  but  it  is  far  from  being  uniformly 
successful.  If  atropia  fails,  pilocarpine  should  be  tried.  Oxide  of  zinc, 
with  belladonna  extract,  sometimes  does  well.  Sponging  the  body  with 
hot  water,  or  vinegar  and  water,  is  a  domestic  remedy,  which  is  refresh- 
ing. The  treatment  of  haemorrhage  will  be  referred  to  again,  and  its 
consideration  is  therefore  postponed.  Remedies  for  the  laryngeal 
symptoms  can  be  applied  directly,  the  hand  being  guided  by  the  mir- 
ror, titrate  of  silver,  carbolic  acid,  and  iodoform  are  the  medicaments 
most  frequently  applied  directly.  Atomization  is,  however,  the  more 
useful  and  generally  employed.  Common  salt,  potassic  chloric,  am- 
monium chloride,  tannic  acid,  and  tar- water  are  the  remedies  most  fre- 
quently used  in  this  way.  To  this  statement  must  now  be  excepted 
benzoate  of  soda,  which  is  being  employed  in  the  most  extraordinary 
fashion.  Already,  soon  after  the  announcement  of  its  curative  power 
in  consumption,  comes  the  statement  that  there  is  but  little  truth  in 
the  first  reports.  The  remedies  above  mentioned  are  dissolved  in 
water,  or  in  glycerine  and  water,  for  example,  gr.  ij  of  tannin  to  the 
ounce  of  water,  and  then  atomized,  the  patient  receiAT-ng  the  spray  in 
the  fauces.  Obviously,  caustic  and  corrosive  remedies  are  not  adapted 
to  such  purposes.  The  diarrhcea  of  phthisis  is  most  difficult  of  control, 
and  for  obvious  reasons — the  tubercular  deposit  and  the  subsequent 

*  Trochisci  glycrrrhizae  et  opii,  each  troche  contains  -^g  grain  of   opium ;  trocliisci 
morphia  et  ipecacuanhae,  each  troche  contains  -^  grain  of  morphia  and  -jV  ipecac. 


HJSMOPTYSIS.  373 

ulcerations.  Opium  and  acetate  of  lead,  opium  and  tannin,  opium  and 
sulphuric  acid,  opium  and  arsenite  of  potassa,  are  among  the  principal 
remedies.  Extract  of  logwood  is  highly  esteemed  by  many  English 
practitioners.  The  author  has  had  better  results  from  Fowler's  solution 
and  the  tincture  of  opium  than  any  other  remedies  (2  gtt. — 10  gtt.) 
except  aromatic  sulphuric  acid  and  laudanum  (15  gtt. — 10  gtt.).  In 
the  treatment  of  the  diarrhoea  frequent  changes  are  necessary.  A 
remedy  that  succeeds  for  a  time  will  not  continue  to  do  so,  and  hence 
the  resources  of  the  physician  are  often  severely  tried.  The  requisites 
of  a  climate  for  pulmonary  invalids  have  been  briefly  stated  ;  they  are 
dryness  and  elevation.  The  health  resorts  which  offer  these  requisites 
in  the  highest  perfection  are  the  best.  Those  of  North  Carolina,  South 
Carolina,  Georgia,  the  Rocky  Mountain  regions,  California,  New  Mex- 
ico, offer  every  variety.  No  change  of  climate,  however,  can  be  bene- 
ficial as  a  rule,  after  cavitiefe  have  been  formed,  unless  of  slight  extent. 
It  is  in  incipient  phthisis  that  a  change  to  a  climate  dry,  bracing,  and 
elevated,  really  exerts  a  curative  influence. 

H.E3M0PTYSIS— BRONCHO-PULMONARY   HEMORRHAGE. 

Definition. —  The  word  haemoptysis,  which  means  "  spitting  of 
blood,"  does  not  indicate  the  source  of  the  haemorrhage.  Broncho- 
pulmonary. h(Bm,orrhage  is  a  correct  designation,  for  this  expresses 
both  the  nature  of  the  accident  and  the  position  of  the  disease.  Bron- 
chial haemorrhage  occurs  from  some  part  of  the  bronchi ;  pulmonary 
haemorrhage  consists  of  two  forms — pulm,onary  infarction  /  pulmo- 
nary apoplexy — a  hasmorrhage  arising  from  embolic  blocking  of  a 
branch  of  the  pulmonary  artery,  the  tissues  of  the  lung  being  dis- 
placed merely  in  the  former,  but  broken  up  in  the  latter. 

Causes. — Pulmonary  haemorrhage  is  infrequent  at  the  extremes  of 
life,  and  is  most  common  from  youth  up  to  middle  life.  It  occurs  in 
either  sex  in  about  the  same  ratio.  An  infarction  presents  a  character- 
istic appearance  of  a  wedge-shaped  portion  of  the  lung  infiltrated  with 
blood,  and  situated  at  the  periphery  of  the  lung,  with  the  base  of 
the  wedge  outwardly.  Infarction  is  almost  always  associated  with 
heart  disease,  in  which  heart-clots  are  formed  on  the  right  side,  and 
emboli  being  detached  pass  into  and  obstruct  a  branch  of  the  pul- 
monary artery.  To  cause  an  infarction,  the  artery  obstructed  must 
be  a  "terminal  artery"  in  the  sense  intended  by  Cohnheim* — that  is, 
an  artery  without  anastomoses,  and  dividing  only  into  the  final  capil- 
laries. When  such  a  vessel  is  obstructed,  the  blood-current  is  arrested 
both  in  front  and  behind  the  point  of  obstruction,  in  the  capillaries 
and  veins,  until  they  are  joined  by  others.  Then  commences  a  back- 
ward current  into  the  capillaries  of  the  occluded  vessel,  and  into  the 
*  "  Untersuchungen  ueber  die  embolischen  Processe,"  Berlin,  1872,  p.  74. 


374  DISEASES   OF   THE   RESPIRATORY  ORGANS. 

vessel  itself,  until  they  are  thoroughly  distended  with  red-blood  cor- 
puscles, and  hence  appear  to  the  eye  as  a  red  spot  having  a  wedge- 
shape.  In  another  form  of  infarction,  a  diseased  vessel  giving  way, 
the  blood  enters  a  bronchus,  and  is  drawn  up  into  the  lobules,  distend- 
ing them.  This  differs  from  the  other  form  in  appearance  ;  it  is  less 
dark  in  color,  is  irregular  in  outline,  and  is  shaded  off  into  the  sur- 
rounding normal  tint. 

Pulmonary  apoplexy  is  a  haemorrhage  which  breaks  up  and  infil- 
trates the  lung,  and  is  usually  due  to  traumatism,  to  gunshot  injuries 
and  contusion,  to  the  rupture  of  aneurisms,  to  gangrene,  etc.  -  Bron- 
chial haemorrhage  arises  from  primary  and  secondary  causes.  The 
primary  causes  are  of  an  irritative  kind,  and  induce  congestion  :  pro- 
longed exertion  of  the  voice,  mechanical  straining,  inhalation  of  irri- 
tating gases  and  fumes,  etc.  An  abnormal  weakness  of  the  vessel- wall 
inherited  ;  that  state  of  the  circulation  which  exists  in  the  subjects  of 
hsemophilia,  the  so-called  "bleeders"  ;  the  condition  of  the  vessels  in 
young  subjects  of  the  sti'unaous  type,  are  factors  in  the  production  of 
i)ronchial  haemorrhage.  The  most  important  of  the  causes  is  tuber- 
culosis. As  has  been  stated  elsewhere,  the  initial  change  in  the  devel- 
oj)ment  of  tubercle  is  a  proliferation  of  the  connective-tissue  corpuscles 
of  the  adventitia  ;  and,  although  the  multiplication  is  chiefly  outwardly, 
the  media  and  intima  are  weakened.  Haemorrhage  may  therefore  be 
an  early  symptom  of  tubercular  deposit.  In  the  extension  of  the  tuber- 
cular deposit  a  vessel  may  be  invaded  at  any  time.  A  large  haemor- 
rhage may  result  from  the  opening  of  a  vessel  by  erosion  in  the  pro- 
cess of  softening  and  formation  of  cavities,  or  by  the  development  of 
an  aneurism  on  a  vessel  in  the  wall  of  a  cavity.  The  vessels  still  per- 
vious are  subjected  to  a  much  greater  pressure  by  reason  of  the  closure 
of  so  many,  and  hence  this  increase  in  the  vascular  pressure  enters  into 
the  question  of  haemorrhage.  The  suppression  of  an  habitual  discharge 
has  long  been  supposed  to  cause  pulmonary  haemorrhage,  but  this  is  no 
longer  admitted.  The  menstrual  flow  may  take  place  vicariously  by 
the  bronchial  mucous  membrane,  as  it  does  by  various  channels.  A 
substitution  is  very  different  from  a  vicarious  haemorrhage. 

Pathological  Anatomy. — Haemorrhage  may  be  caused  by  a  diape- 
desis  of  red-blood  globules,  and  hence  no  solution  of  continuity  can  be 
detected  under  such  circumstances.  Even  when  there  has  been  a  con- 
siderable haemorrhage,  the  source  of  it  may  elude  the  most  painstaking 
investigations.  If  the  examination  is  made  immediately  after  a  haem- 
orrhage, there  will  be  found  both  fluid  and  coagulated  blood,  drawn 
up  into  the  bronchioles  and  alveoli,  and  through  the  larger  tubes.  In 
consequence  of  violent  struggles  for  breath,  in  the  case  of  large  haem- 
orrhage, the  inspiratory  efforts  draw  up  a  good  deal  of  blood  into  the 
lungs,  distending  them,  so  that  they  overlap  the  heart  and  do  not  col- 
lapse.    They  present  a  mottled  appearance,  because  of  the  filling  of 


HiEMOPTYSIS.  375 

many  alveoli  with  blood.  The  mucous  membrane  of  the  bronchi  may 
be  congested  or  reddened  by  jDatches  of  extravasation,  or  of  a  dull-red 
by  imbibition  of  blood,  or  uniformly  pale  from  anaemia,  according  to 
the  causes  producing  it  and  the  source  of  the  haemorrhage.  The  in- 
farction presents  a  most  characteristic  appearance  :  it  is  wedge-shaped, 
with  the  base  outward,  and  is,  when  small,  just  under  the  pleura  ;  when 
large,  nearer  the  root  of  the  lung.  Infarctions  vary  in  size,  from  a 
pigeon's  to  a  hen's  egg,  or  may  even  occupy  a  half  or  nearly  the  whole 
of  a  lobe.  They  are  found  more  frequently  in  the  inferior  part  of  the 
lower  lobe.  If  under  and  next  the  pleura,  they  appear  as  dark-blue 
masses,  projecting  somewhat  above  the  general  surface  of  the  lung, 
which  just  about  the  infarction  is  pale  and  exsanguine,  while  the  pleura 
is  roughened  by  exudation,  and  confined  to  the  infarction.  Some- 
times effusion  occurs  in  the  pleural  cavity,  which  contains  flocculi  of 
membranous  exudation,  and  is  red  by  admixture  with  blood.  When  a 
section  is  made  through  an  infarction,  it  appears  as  a  dark,  reddish- 
blue,  well-defined  mass,  from  which  some  dark,  reddish-brown  liquid 
and  granular  matter  may  be  pressed.  Fibrinous  exudation,  distending 
some  of  the  alveoli,  gives  to  the  otherwise  smooth  surface  a  granular 
aspect.  At  first  firm  and  elastic,  the  infarction  soon  becomes  friable. 
The  surrounding  pulmonary  tissue  is  more  or  less  hypersemic  and 
cedematous.  An  infarction  may  undergo  several  kinds  of  change  :  the 
blood  may  disintegrate,  the  fibrin  become  granular  and  fatty,  and  the 
corpuscles  break  up  into  fat-granules  ;  absorption  may  take  place  in 
part,  extrusion  in  part,  and  recovery  ensue,  the  elasticity  of  the  lung 
remaining  impaired  to  some  extent.  Recovery  may  ensue  in  part 
only  :  the  lobules  collapsing  and  inflammation  occurring  in  the  con- 
nective tissue,  a  brownish-red  indurated  mass  remains  ;  or,  after  an 
imperfect  absorption  of  the  blood  and  inflammatory  exudation,  the 
remaining  reddish,  pulpy  mass  solidifies  by  infiltration  with  calcareous 
salts,  or,  merely  inclosed  by  a  limiting  membrane,  a  cyst  remains — a 
process  only  resembling  hsematoma  of  the  dura  mater.  Or,  again, 
inflammation  may  result  in  suppuration,  an  abscess  forming  ;  or,  finally, 
the  whole  may  become  gangrenous.  Pulmonary  apoplexy  not  unfre- 
quently  forms  a  blood-mass  of  considerable  size,  the  blood  breaking 
up  the  pulmonary  elements  and  diffusing  into  the  surrounding  parts, 
in  part  coagulating.  If  next  the  pleura,  this  membrane  may  be  per- 
forated, and  the  blood,  entering  the  cavity,  produce  a  hsemothorax. 

Symptoms. — It  is  but  rarely  that  a  hemorrhage  occurs  in  full  health 
without  the  least  intimation  of  its  approach.  In  this  way  may  the 
onset  of  pulmonary  disease  be  announced.  Usually  there  is  a  sense  of 
heat  and  oppression  of  the  chest,  which  those  recognize  who  have 
experienced  former  attacks,  or  there  may  be  general  vascular  full- 
ness, headache,  vertigo,  palpitation  of  the  heart,  a  quick,  strong  pulse, 
etc.     The  signs   of  pulmonary  disease  precede  the  haemorrhage,  in 


3Y6  DISEASES   OF   THE   RESPIKATORY   ORGANS. 

a  majority  of  cases,  rather  than  succeed  to  it.  At  the  moment  the 
attack  is  experienced,  there  are  a  sudden  cough,  a  warm  feeling  under 
the  sternum,  and  a  mouthful  of  fluid,  tasting  both  saltish  and  sweet- 
isli,  comes  up.  Cough  now  succeeds  cough,  and  with  each  effort  a 
teaspoonful  or  more  of  blood,  somewhat  frothy,  or,  if  in  large  quan- 
tity, bright — red  blood  and  somewhat  darker  clots,  are  discharged. 
Even  with  a  small  amount  of  blood,  the  moral  effect  of  the  blood-spit- 
ting is  so  great  that  much  depression,  paleness  of  the  face,  and  a  weak 
pulse  result.  If  the  loss  be  great,  there  will  come  on  the  subjective 
sensations  of  fainting,  and  actual  syncope  will  happen.  If  the  hgemor- 
rhage  is  great,  the  blood  will  come  up  with  a  sudden  gush,  spurting 
from  the  nose  as  well  as  the  mouth.  If  a  fatal  haemorrhage,  the  blood 
will  pour  out  of  the  mouth  and  nose,  there  will  be  gurgling  in  the 
fauces,  frantic  efforts  at  respiration,  a  deadly  pallor  will  overspread  the 
face,  and,  with  a  general  convulsion  in  which  the  breathing  ceases,  all 
is  over,  but  the  heart  will  beat  for  a  minute  longer.  The  expectora- 
tion of  blood  does  not  cease  with  the  arrest  of  the  haemorrhage  ;  for 
some  days  subsequently  dark-brownish  coagula  will  be  brought  up,  with 
some  rather  viscid  mucus.  The  source  of  the  haemorrhage  may  not 
unfrequently  be  determined  by  the  moist  rales  heard  in  the  bronchi. 
The  signs  and  symptoms  of  infarction  have  already  been  mentioned 
under  the  head  of  embolic  pneumonia,  so  that  it  is  necessary  only  to 
mention  that,  when  an  infarction  of  sufficient  size  is  formed,  the  symp- 
toms are  sudden  dyspnoea  and  the  physical  signs  of  consolidation. 

Course,  Duration,  and  Termination. — There  are  great  variations  in 
the  amount  and  duration  of  pulmonary  haemorrhage.  The  whole 
course  may  be  concluded  in  a  few  hours.  The  expectoration  may  go 
on  during  several  days,  from  a  tea-  to  a  tablespoonful  being  spat  up 
each  time,  and  the  haemorrhage  in  the  aggregate  amounting  to  several 
pounds,  causing  great  depression  and  a  tedious  convalescence.  In 
other  cases,  there  may  be  a  number  of  large  haemorrhages,  occurring 
after  an  interval  of  several  days,  the  arrest  being  due  to  syncope,  and 
the  hcsmorrhage  recurring  when  sufficient  blood  has  been  made  to  pro- 
duce it.  Such  cases  may  continue  for  several  weeks,  the  system  being 
much  reduced  and  the  convalescence  very  protracted.  In  cases  of 
haemorrhage  with  infarction  there  will  follow  a  period  of  inflammatory 
reaction,  the  expectoration  will  continue  bloody  for  a  week  or  ten 
days,  and,  if  the  area  of  tissue  involved  is  small,  recovery  will  ensue, 
and  convalescence  will  be  established  in  about  ten  days.  The  reader 
is  referred  to  embolic  pneumonia  for  further  details  in  respect  to  this 
group  of  cases.  An  ordinary  croupous  pneumonia  may  be  accom- 
panied by  considerable  haemorrhage,  which  occurs  with  the  initial 
hyperaemia,  when  the  pneumonic  process  r:ay  be  confounded  with 
the  results  of  haemorrhage.  The  debility  caused  by  pulmonary 
haemorrhage  is  quite  disproportioned  to  the  actual  loss.     A  few  tea- 


HEMOPTYSIS.  3Y7 

spoonfuls  may  induce  fainting  and  an  unexpected  degree  of  anaemia. 
Any  considerable  loss  will  be  followed  by  pallor,  weakness,  breathless- 
ness  on  slight  exertion,  palpitation,  etc.,  and  the  restoration  of  the 
blood  will  require  several  weeks  or  months.  The  moral  effect  of  the 
haemorrhage  and  the  association  of  ideas  connected  with  the  bleeding 
are  in  part  responsible  for  the  depression,  but  more  is  due  to  the  fact 
that,  in  most  cases,  the  system  is  already  enfeebled  by  a  dyscrasia. 
To  this  important  element  is  also  due  the  prolonged  condition  of 
anaemia — the  slow  reproduction  of  the  red-blood  corpuscles. 

Diagnosis. — In  every  case  of  doubt,  the  mouth,  fauces,  and  nares 
should  be  carefully  examined.  Is  it  vicarious  haemorrhage  ?  The 
patient  is  a  female,  the  haemorrhage  occurs  at  the  menstrual  epoch, 
and  takes  the  place  of  the  menses,  or  nearly  so,  and  no  untoward  re- 
sults are  experienced,  nor  does  any  evidence  of  pulmonary  disease 
exist.  In  many  of  these  supposed  vicarious  haemorrhages  it  will  be 
found  that  the  subjects  are  of  the  phthisical  type,  and  that,  if  the 
physical  signs  are  wanting,  there  are  suspicious  rational  symptoms. 
In  these  cases,  it  usually  happens  that  the  menstrual  flow  does  not 
return,  and  that  phthisis  rapidly  develops.  Haemoptysis  is  to  be  dif- 
ferentiated from  haematemesis.  In  the  latter,  the  blood  is  black,  con- 
tains no  air,  has  an  acid  reaction,  is  mixed  with  articles  of  food,  and 
is  vomited  ;  in  the  former,  the  blood  is  bright  red,  contains  air,  has 
an  alkaline  reaction,  and  is  coughed  up,  while  there  is  no  nausea.  If 
the  blood  of  pulmonary  haemorrhage  is  swallowed,  it  will  present  the 
characteristics  of  blood  derived  directly  from  the  stomach,  but  the 
distinction  is  then  made  by  observing  that  some  of  the  blood  is 
coughed  up,  and  has  the  ordinary  character  of  blood  derived  from  the 
lungs.  It  should  be  noted  that  blood  swallowed  may  pass  away  with 
the  stools.  Haemoptysis  is  accompanied  by  rales  in  the  chest,  and 
preceded  in  the  largest  number  of  cases  by  symptoms  referable  to  the 
chest ;  haematemesis  by  symptoms  referable  to  the  stomach. 

Prognosis. — It  is  very  rare  indeed  for  the  life  to  be  put  in  jeop- 
ardy by  a  pulmonary  haemorrhage.  If  the  patient  is  much  reduced,  a 
severe  haemorrhage  may  materially  hasten  a  fatal  result.  Haemor- 
rhage proceeding  from  a  cavity  is  more  unfavorable  than  a  bronchial 
haemorrhage,  for  the  vessel  may  bleed  again  and  again,  since  any  co- 
agulum,  which  in  other  situations  might  close  it,  will  here  be  readily 
detached.  The  prognosis  must  be  guarded  when  the  subject  of  the 
haemorrhage  is  much  reduced  and  the  quantity  lost  is  considerable. 
In  a  case  of  supposed  vicarious  haemorrhage,  the  probability  of  a 
rapid  development  of  the  pulmonary  lesion  should  not  be  forgotten. 

Treatment. — The  management  of  cases  of  haemoptysis  includes  the 
treatment  of  the  haemorrhage  and  of  the  conditions  on  which  the 
haemorrhage  depends.  If  the  subject  be  a  plethoric  one,  and  there  is 
niuch  oppression  from  fullness  of  the  vascular  system,  bloodletting 


378  DISEASES   OF   THE   EESPIRATORY   ORGANS. 

may  be  practiced,  either  venesection  to  eight  ounces,  or  a  dozen  leeches. 
These  are,  it  must  be  admitted,  rare  cases.  The  most  effective  remedy 
is  the  hypodermatic  injection  of  ergotin.  Often,  the  most  severe  bleed- 
ing will  be  at  once  arrested,  when  other  means  of  treatment  had  been 
employed  in  vain.  Fluid  extract  of  ergot  may  be  given  internally, 
combined,  if  desirable,  with  digitalis  and  opium — ^with  digitalis  if  the 
action  of  the  heart  is  rapid  and  excited,  and  with  opium  if  there  is  a 
troublesome  cough.  Ipecac  is,  next  to  ergotin,  one  of  the  most  efficient 
haemostatics.  Its  utility  has  been  disputed  on  theoretical  grounds,  but 
not  by  those  who  are  practically  acquainted  with  its  real  advantages. 
Ipecac  produces  an  exsanguine  condition  of  the  lung,  and  arrests  haem- 
orrhage also,  by  the  enfeebling  effect  of  nausea  on  the  heart.  It  is 
even  successful  in  stopping  post-partmn  haemorrhage.  Besides  its 
haemostatic  effect,  the  advantage  of  its  use  consists  in  mechanically 
clearing  the  alveoli  of  retained  clots.  Ipecac  should  not  be  prescribed 
in  those  cases  of  haemorrhage  from  a  cavity,  the  difficulty  of  keeping 
a,  clot  in  the  position  necessary  to  close  the  vessel  being  already  great. 
The  most  suitable  form  for  the  use  of  ipecac  is  the  fluid  extract,  which 
may  be  combined  with  ergotin,  digitalis,  and  opium  if  desirable.  Tinc- 
ture of  veratrum  viride  may  be  used  with  great  advantage  to  keep  down 
the  action  of  the  heart.  Ice  has  a  similar  effect  to  these  dynamical 
haemostatics  ;  it  slows  the  heart  and  contracts  the  arterioles.  It  should 
be  applied  to  the  chest,  especially  to  the  nape  of  the  neck.  The  alter- 
nate application  of  heat  and  cold  is  usually  more  effective  than  the 
continuous  cold.  A  sponge  dipped  in  hot  water  can  be  applied  first, 
then  an  ice-bag,  and  so  on  alternating — the  heat  remaining  in  contact 
but  a  few  minutes,  while  the  cold  is  kept  applied  the  rest  of  the  time. 
Absolute  rest  is  an  agent  of  the  same  kind.  The  patient  should  main- 
tain a  recumbent  posture,  and  not  exert  a  muscle  if  he  can  exercise 
such  restraint.  All  emotional  disturbances  should  be  avoided  as  well. 
There  are  remedies  called  astringents  which  are  supposed  to  possess 
haemostatic  powers,  such  as  tannic  and  gallic  acids,  acetate  of  lead, 
alum,  and  the  mineral  acids,  especially  sulphuric.  These  are  decidedly 
inferior  to  the  remedies  above  named,  yet  they  are  freely  used,  espe- 
cially the  acetate  of  lead  in  combination  with  opium.  That  they  are 
serviceable,  an  immense  experience  confirms,  but  they  do  not  deserve 
the  very  great  confidence  reposed  in  them  by  many  practitioners.  In 
cases  of  debility,  characterized  by  relaxation  of  tissue,  or  in  examples 
of  the  hsemorrhagic  diathesis,  or  in  cases  of  purpura,  oil  of  turpentine 
is  highly  useful.  Inhalations,  by  the  atomizer,  or  spray  douche,  of  a 
solution  of  Monsel's  salt  (subsulphate  of  iron)  or  the  chloride  of  iron, 
will  sometimes  arrest  a  violent  haemorrhage  at  once.  This  undoubted 
fact  is  all  the  more  difficult  of  explanation,  since  but  little,  very  little, 
of  the  iron  salt  can  pass  the  chink  of  the  glottis,  and  none  of  it  can 
reach  the  point  of  disease  in  the  lung.     Tannin  in  solution  may  be  em- 


HJEMOPTYSIS.  379 

ployed  in  the  same  way,  but  the  iron  spray  is  distinctly  better.  In 
administering  iron  spray  great  care  must  be  exercised  to  protect  the 
teeth  and  the  clothing,  which  may  be  permanently  stained,  A  mouth- 
ful of  common  salt  is  a  domestic  remedy,  which  may  be  used  until  more 
efficient  means  are  available.  Counter-irritants  are  serviceable.  A 
mustard-plaster  or  a  flying-blister  is  sufficiently  active,  or  a  turpentine 
liniment,  the  latter  being  useful  also  because  of  its  vapor.  Good  re- 
sults may  be  obtained  by  inhalation  of  the  vapor  of  turpentine  disen- 
gaged for  this  purpose  in  those  cases  appropriate  for  its  internal  ad- 
ministration. If  the  hsemorrhage  has  shown  a  disposition  to  recur,  the 
recumbent  position,  quietude  of  mind,  and  the  remedies  employed  to 
check  it,  if  not  objectionable,  should  be  continued  until  all  possibility 
of  danger  has  passed. 


HYPEREMIA  AND   CEDEMA   OF  THE   LUNGS. 

Definition. — IIyper(Mmia  signifies  an  abnormal  increase  in  the  blood- 
supply,  which  may  be  active  or  passive.  (Edema  is  usually  a  conse- 
quence of  hypersemia,  but  it  may  be  due  to  causes  producing  general 
cedema.  The  term  signifies  the  presence  of  serous  fluid  in  the  alveoli, 
the  intervening  connective  tissue,  the  perivascular  lymph-spaces,  etc. 

Causes. — There  may  be  an  increase  in  the  amount  of  blood  going 
to  the  lungs,  the  result  of  increased  pressure  in  the  arterial  system, 
from  greater  force  of  the  heart's  contractions,  or  from  narrowing  of 
the  arterial  field  elsewhere,  throwing  an  additional  quantity  on  the 
lung.  Undue  exercise  of  the  vocal  apparatus  in  speaking  or  singing, 
the  inhalation  of  cold,  or  very  warm  air,  or  the  sudden  transition  from 
one  extreme  of  temperature  to  the  other,  and  the  inhalation  of  irritat- 
ing gases  or  vapors,  are  causes  determining  congestion  of  the  lungs 
under  favoring  circumstances.  The  form  and  character  of  the  chest 
and  the  existence  of  a  constitutional  vice  or  dyscrasia  are  necessary  to 
bring  about  the  results  from  the  operation  of  such  causes,  especially 
the  type  of  chest  and  the  bodily  conformation  of  phthisical  subjects. 
The  ingestion  of  cold  drinks,  the  body  in  a  warm  and  perspiring  state, 
will  sometimes  induce  extreme  congestion  of  the  lungs.  The  sudden 
impact  of  cold  air  or  cold  water  on  the  surface  will  more  surely  pro- 
duce the  same  result,  since  a  larger  surface  of  the  capillaries  is  made 
to  contract,  forcing  the  blood  within.  One  part  of  the  lung,  the  seat 
of  a  disease  obstructing  the  circulation  in  it,  will  necessarily  throw  on 
another  part  an  excess  in  its  supply  ;  pneumonia,  atelectasis,  and  obstruc- 
tion in  some  branches  of  the  pulmonary  artery,  are  examples.  Pas- 
sive congestion  is  produced  by  causes  interfering  with  the  return  of 
blood  from  the  lung  ;  mitral  stenosis  and  insufficiency,  aortic  stenosis 
and  insufficiency,  and  obstructive  lesions  maintaining  venous  stasis,  are 
examples.     A  weak  heart  may  produce  the  same  result  by  insufficiency 


380  DISEASES   OF   THE   RESPIRATORY   ORGANS. 

in  propulsive  power,  and  hypostatic  congestion  results  from  such  a  state 
of  adynamia  that  the  blood  simply  obeys  the  force  of  gravity.  (Edema 
is  a  result  of  congestion,  whether  active  or  passive,  or  a  local  effect  of 
the  causes  producing  a  genei'al  dropsy. 

Pathological  Anatomy. — When  the  lung  is  congested  it  is  heavier, 
contains  less  air  and  more  blood,  and  crepitates  less  than  is  normal. 
The  color  is  darker  and  redder  ;  on  section  it  is  found  to  contain  more 
fluid  in  the  interstices,  more  blood  flows  out  from  the  divided  vessels, 
and  the  bronchi  are  injected  and  filled  with  a  sanguinolent,  frothy 
serum.  In  chronic  cases  the  congestion  is  considerable,  the  color  of 
the  affected  portions  is  dark  red,  almost  blackish  red  ;  the  interstitial 
connective  tissue  is  distended  with  serum,  the  capillaries  are  so  swol- 
len as  to  compress  the  alveoli,  almost  or  quite  obliterating  the  cavity, 
and  numerous  extravasations  are  found  through  the  parenchyma.  So 
firm  and  dark  becomes  the  tissue  of  the  lung  as  to  resemble  the  appear- 
ance of  the  spleen,  whence  the  term  splenization  to  characterize  this 
condition.  In  the  dependent  portions  of  the  lungs  of  the  very  adynam- 
ic or  of  aged  persons  confined  to  a  recumbent  position,  a  serous  fluid, 
having  considerable  viscidity,  exudes,  giving  to  the  lung  on  section  a 
somewhat  granular  aspect,  whence  the  term  hypostatic  pneumonia. 
In  oedema  there  is  a  serous  infiltration  into  the  interstitial  connective 
tissue  and  in  the  alveoli,  which  may  be  sufficient  to  distend  the  lung 
and  afford  pitting  on  pressure.  On  section  of  the  lung  under  these 
circumstances,  a  quantity  of  serum  flows  out  ;  the  serum  is  reddish 
when  there  is  much  congestion  associated  with  the  oedema.  When 
oedema  of  the  lung  coexists  with  general  dropsy,  the  fluid  that  exudes 
is  colorless,  and  the  tissue  of  the  lung  is  pale.  The  dependent  and 
inferior  portions  of  the  lungs  first  become  oedematous  ;  thence  it  spreads 
to  the  superior  and  anterior  portions  as  the  fluid  increases  in  amount. 
As  a  result  of  congestion  of  the  passive  kind,  due  to  disease  of  the 
mitral  valve,  the  lungs  generally  become  denser,  more  resistant,  and 
are  much  increased  in  size.  The  color,  externally,  varies  from  a  red- 
dish-yellow to  a  brown,  and  on  section  its  texture  is  found  to  be  firm,  to 
crepitate  but  little,  to  exude  blood  very  freely,  and  not  only  blood, 
but,  on  pressure,  to  exude  a  yellowish  or  brownish  fluid.  While  the 
general  color  of  the  divided  surface  is  yellowish-red  or  brownish-yel- 
low, there  are  spots  interspersed  having  a  brownish  almost  blackish 
color — whence  the  designation  brown  induration.  Some  of  these  brown 
spots  are  very  dense,  and  sink  in  water. 

Symptoms. — A  sudden  and  complete  congestion  of  both  lungs  may 
be  a  cause  of  sudden  death.  Between  this  extreme  and  a  simple  uni- 
lateral congestion  of  slight  extent,  there  are  numerous  gradations  in  the 
severity  of  the  seizures.  In  the  mildest  cases  there  occur  a  sense  of 
internal  heat,  oppression  of  the  chest,  some  slight  difficulty  of  breath- 
ing, a  flushed  face,  a  strong,  full  pulse,  beating  of  the  carotids,  and  in- 


HYPERJJMIA  AND   (EDEMA  OF  THE   LUXG.  381 

jection  and  brilliancy  of  the  eyes.  When  the  congestion  is  sufficient 
to  cause  universal  oedema  of  the  alveoli,  the  symptoms  are  formidable. 
There  are  great  difficulty  and  extreme  rapidity  of  breathing,  a  strong 
sense  of  oppression,  intense  anxiety,  rapid  and  violent  action  of  the 
heart,  beating  carotids  and  pulsation  in  the  temples,  headache  and 
fullness  of  the  head,  a  flushed  face,  a  hasty  and  troubled  cough,  and 
expectoration  of  a  frothy  liquid  which  may  be  tinted  with  blood. 

On  percussion  the  resonance  of  the  lungs  is  but  little  altered — 
slightly  diminished,  with  a  tympanitic  quality.  The  vesicular  murmur 
is  supplanted  by  sub-crepitant  and  mucous  rales,  which  are  very  abun- 
dant and  very  loud.  If  the  alveoli  are  filled  with  fluid,  the  sonority 
will  be  still  more  diminished,  and  the  respiration  will  have  a  blowing 
character  approaching  bronchophony.  If  the  alveoli  are  filled  to  that 
degree  that  the  oxygen  can  not  reach  the  blood,  accumulation  of  car- 
bonic acid  must  take  place,  and  hence  there  will  be  blue  lips,  a  livid 
face,  headache,  etc.  When  this  condition  is  reached,  there  will  be  still 
greater  anxiety  and  oppression,  the  breathing  will  be  shallow  and  ex- 
ceedingly hurried,  the  pulse  will  decline  in  volume,  and  at  length  will 
be  merely  thready  and  intermittent,  the  surface  of  the  body  will  be 
cold  and  covered  with  a  clammy  sweat,  the  fingers  will  be  blue  and 
cold,  and  with  the  accumulation  of  carbonic  acid  there  will  be  in- 
creasing somnolence,  replacing  the  extreme  restlessness,  deepening 
into  coma.  With  the  increasing  stupor  there  will  be  less  and  less 
effort  at  cough  and  expulsion  of  the  fluid  accumulating  in  the  bronchi, 
and  an  increasing  difficulty  of  breathing  from  this  cause.  In  the  cases 
of  passive  congestion  of  the  lungs,  due  to  cardiac  disease,  there  are 
difficulty  of  breathing,  cough  and  oppression,  constantly  present,  and 
paroxysms  of  extreme  dyspnoea,  in  which  the  patient  labors  for  breath, 
the  face  is  cyanosed,  the  extremities  cold  and  blue,  the  skin  cold  and 
covered  with  a  clammy  sweat,  the  pulse,  small,  weak,  and  irregular, 
the  jugulars  swollen,  the  mind  clouded,  etc.  The  severity  of  these 
attacks  will  be  greatly  increased  if  oedema  come  on  suddenly ;  but  if 
the  oedema  is  gradual  in  forming,  the  difficulties  of  breathing  will  be 
slowly  augmented,  and  carbonic-acid  poisoning  will  also  be  slowly  de- 
veloped. The  physical  signs  in  cases  of  hypostatic  congestion  will 
indicate  the  existence  of  bilateral  lesions  if  the  decubitus  is  dorsal ;  or 
unilateral,  if  the  decubitus  is  to  one  side.  The  sonority  is  diminished, 
or  dullness  with  a  tympanitic  quality  exists.  On  auscultation,  the  ve- 
sicular murmur  will  be  weak,  or  supplanted  by  moist  rales.  The  dif- 
ficulty of  breathing  which  arises  during  chronic  Bright's  disease  is  due 
to  oedema  of  the  bronchial  mucous  membrane — an  interstitial  oedema 
and  swelling  of  the  terminal  bronchi. 

Course,  Duration,  and  Termination. — An  acute  congestion  of  the 
lungs  may  pass  through  its  whole  course  and  prove  fatal  within  a  few 
hours.     The  usual  duration  is  from  three  to  five  days,  and  the  termi- 


382  Diseases  of  the  respiratory  organs. 

nation  'may  be  by  resolution,  occasionally  by  lisemorrhage,  and  rarely 
by  inflammation  or  pneumonia.  The  passive  form  associated  with 
cardiac  disease  develops  slowly,  and  is  subjected  to  great  variations ; 
to  periods  of  improvement  under  appropriate  treatment ;  then  exacer- 
bations. Acute  oedema  may  come  on,  and  prove  quickly  fatal  in  acute, 
or  chronic  kidney  affections. 

Diagnosis. — Active  congestion  is  to  be  distinguished  from  the  stage 
of  engorgement  in  pneumonia.  The  points  of  difference  are :  in 
congestion  there  are  no  chill,  no  pain  in  the  side,  and  not  the  range 
of  temperature  of  pneumonia.  The  subsequent  course  separates  the 
two  diseases  more  widely.  CEdema  occurring  during  hyperemia  is 
announced  by  dyspnoea,  by  the  auscultatory  signs  of  the  presence  of 
fluid  in  the  terminal  bronchi,  and  by  the  expectoration  of  a  frothy, 
serous,  and  reddish  fluid.  The  hypersemia  of  a  passive  kind  produced 
by  valvular  lesions  is  accompanied  by  rational  and  physical  signs, 
which  make  the  diagnosis  merely  a  question  of  the  recognition  of 
these  signs. 

Treatment. — Active  congestion  in  a  plethoric  subject  may  demand 
bloodletting,  if  not  by  venesection,  by  the  application  of  cups  or 
leeches  to  the  chest.  A  ligature  to  the  thighs  applied  merely  firmly 
enough  to  retain  the  blood  in  the  superficial  veins  is  a  useful  expedi- 
ent when  the  abstraction  of  blood  may  seem  to  be  necessary.  Coun- 
ter-irritation in  the  form  of  a  large  mustard-plaster  should  be  applied 
to  the  chest,  and  the  feet  should  be  put  in  a  hot  foot-bath.  As  the 
removal  of  the  fluid  in  the  alveoli  and  terminal  bronchi  is  of  the 
utmost  necessity,  an  active  emetic  should  be  prescribed  ;  of  these 
apomorphia  subcutaneously  is  probably  the  best,  and  next,  the  sub- 
sulphate  of  mercury.  Stimulant  expectorants  should  be  prescribed 
to  procure  the  expulsion  of  the  fluid  by  expectoration.  Squill,  senega, 
and  serpentaria  are  appropriate  remedies  for  this  purpose.  To  dimin- 
ish the  viscidity  of  the  fluid,  and  thus  secure  its  easy  expulsion,  the 
iodides,  especially  the  iodide  of  ammonium,  are  highly  serviceable.  The 
iodide  and  carbonate  of  ammonium  in  sirup  of  senega  is  an  excellent 
combination  to  secure  the  rapid  and  easy  extrusion  of  the  fluid  pres- 
ent. In  the  oedema  of  cardiac  disease  and  renal  dropsy,  digitalis  and 
squill  are  very  important  remedies.  If  the  blood  is  much  impover- 
ished, iron  is  indicated,  especially  the  iodide  of  iron,  which  is  a  rapidly 
acting  and  an  efiicient  chalybeate.  When  there  is  hypostatic  conges- 
tion, changes  in  the  position  of  the  patient  are  very  necessary,  and 
the  propulsive  power  of  the  heart  must  be  increased  by  stimulants, 
quinine,  and  small  doses  of  opium.  In  the  cases  of  brown  induration, 
the  iodide  and  carbonate  of  ammonium  should  be  persistently  used 
together,  with  means  to  increase  the  energy  of  the  heart,  such  as  tur- 
pentine, eucalyptol,  and  alcoholic  stimulants. 


ATELECTASIS.  383 

ATELECTASIS.  " 

Definition. — This  term  means  a  collapse  of  the  lobules,  so  that  the 
cavity  disappears  and  the  walls  approximate.  Congenital  atelectasis 
is  the  state  in  which  the  lungs  are  before  being  dilated  with  air  (foetal 
lung). 

Causes. — The  congenital  condition  is  simply  a  failure  to  distend 
the  alveoli.  The  whole  lung  may  be  in  such  a  state,  or  only  a  part  of 
it,  in  a  premature  child,  or  one  so  weak  at  full  term  as  to  be  unable 
to  expand  the  lungs  fully,  and  hence  some  of  the  lobules  or  alveoli 
remain  in  a  state  of  atelectasis.  The  acquired  atelectasis  is  the  col- 
lapse of  lobules  that  have  been  expanded.  A  terminal  bronchus  may 
be  closed  against  the  admission  of  air  by  a  plug  of  mucus  which,  act- 
ing like  a  ball-valve,  permits  the  exit,  but  not  the  entrance,  of  air,  so 
that  gradually  all  the  residual  air  is  expelled,  and  then  the  sides 
approximate,  and  the  cavity  is  closed — in  other  words,  it  has  col- 
lapsed. This  result  is  the  more  apt  to  occur  in  the  case  of  feeble, 
ill-nourished,  and  ill-developed  children,  who  are  attacked  with  such 
troubles  as  measles,  whooping-cough,  etc.  Collapse  of  lobules — of  a 
large  part  of  a  lung,  indeed — may  be  induced  by  pressure  on  a  bron- 
chus, of  an  aneurism,  of  enlarged  bronchial  glands,  tumors,  etc.  The 
air  remaining  in  lobules,  to  which  the  access  of  air  is  cut  off,  is 
gradually  absorbed  by  the  blood.  Direct  pressure  may  also  cause 
atelectasis — such  direct  pressure  as  is  made  by  hydrothorax,  empy- 
ema, hydropericardium,  aneurisms,  tumors  of  the  thorax,  and  effu- 
sions in  the  peritoneal  cavity,  sufficient  to  push  up  the  diaphragm. 

Pathological  Anatomy. — Seen  from  without,  those  portions  of  the 
lung  in  the  atelectatic  condition  have  a  bluish-red  color,  or  grayish, 
and  are  depressed  somewhat  below  the  general  surface  of  the  organ. 
These  parts  have  a  greater  density  than  the  healthy  tissue,  and,  as 
they  do  not  contain  air,  do  not  crepitate  on  pressure,  and  they  are 
tough  and  not  easily  broken  up.  When  divided,  but  little  blood 
flows  out,  nor  do  they  contain  any  kind  of  fluid,  and  appear  smooth 
instead  of  granular.  When  inflated  with  air,  as  freshly  atelectatic  lung 
can  be,  an  immediate  change  in  color  ensues,  the  lobules  become  pink, 
and  crepitate  on  pressure  as  normal  lung.  If,  however,  they  contin- 
ued collapsed,  changes  of  a  nutritional  kind  ensue,  and,  after  a  time, 
dilatation  can  not  be  effected.  When  congenital,  this  condition  is 
found  to  exist  in  the  posterior  and  inferior  parts  of  the  lungs,  in  the 
apices  and  anterior  borders,  and  may  be  limited  to  individual  lobules, 
or  a  considerable  part  of  a  lobe  may  be  affected.  When  atelectasis  is 
acquired,  usually  isolated  lobules,  or  small  groups  of  lobules,  are  thus 
affected,  they  are  more  or  less  thickly  disseminated  through  both  lungs, 
and  the  superficial  portions  are  first  attacked,  the  deeper  parts  subse- 
quently.    This  acquired  atelectasis  differs  from  the  other  in  that  the 


384  DISEASES   OF   THE   RESPIRATORY   ORGANS. 

collapsed  parts  contain  more  blood  and  serum,  and  hence  there  is  a 
marked  difference  in  appearance  of  the  affected  and  surrounding 
surfaces,  since  the  latter  are  distended  with  air,  and  paler ;  are,  in 
fact,  in  the  condition  of  vicarious  emphysema.  The  pleura  is  usu- 
ally normal ;  it  may  be  somewhat  congested  and  thickened.  The 
situation  of  the  collapsed  lobules  is  due  to  the  position  of  the  com- 
pressing force.  If  the  force  of  the  compression  has  not  been  suffi- 
cient to  drive  all  the  blood  and  air  out,  it  is  then  said  to  be  carnified  ; 
if  all  blood  and  air  are  excluded,  the  color  is  grayish,  and  the  tex- 
ture is  firm. 

Symptoms. — In  congenital  atelectasis,  symptoms  are  produced  only 
in  the  event  that  a  considerable  number  of  lobules  are  collapsed,  when 
the  chief  sign  is  imperfect  respiration.  The  thorax  has  but  little  am- 
plitude of  movement,  the  breathing  is  rapid  but  superficial,  and  the 
voice  is  nothing  more  than  a  husky  whisper.  So  rapid  is  the  breath- 
ing, and  urgent  the  need  of  air,  that  a  child  so  affected  nurses  with 
diflaculty,  or  not  at  all.  The  supply  of  oxygen  being  inadequate,  car- 
bonic acid  accumulates  ;  the  lips  are  blue,  the  extremities  blue  and 
cold,  and  very  feeble,  and  there  are  drowsiness,  muscular  twitchings, 
and  possibly  convulsions  and  paralysis.  In  the  acquired  form,  the 
collapse  of  the  lobules  is  preceded  by  bronchitis  of  the  finer  tubes. 
When  the  atelectasis  occurs,  the  difficulty  of  breathing  increases,  there 
is  corresponding  frequency,  and  the  movements  of  the  two  sides  may 
be  unequal  if  there  be  a  limitation  to  one  lung.  In  inspiration,  instead 
of  expansion  of  the  chest  in  all  directions,  there  is  retraction  of  the 
intercostal  spaces,  and  of  the  inferior  ribs,  due  to  the  fact  that  the 
lungs  can  not  be  expanded.  The  significance  of  the  physical  signs 
will  depend  on  the  extent  to  which  the  atelectasis  has  proceeded.  If 
isolated  lobules  only  collapse  here  and  there,  and  the  adjacent  lobules 
are  dilated  (vicarious  emphysema),  there  will  be  no  appreciable  change 
in  the  sonority.  If,  however,  a  group  may  be  collapsed  of  consider- 
able extent,  there  will  be  dullness,  but  the  note  will  have  somewhat 
the  tympanitic  quality.  The  changes  on  auscultation  will  depend 
equally  on  the  amount  of  tissue  in  the  condition  of  collapse.  The  re- 
spiratory murmur  will  be  replaced  by  bronchial  sounds  if  there  are 
a  large  number  of  lobules  atelectatic.  These  sounds  will  also  change 
with  the  alterations  in  the  affected  parts — an  increase  of  the  collapse 
will  enlarge  the  area  of  dullness  ;  improvement  in  the  local  condition 
and  the  reentrance  of  air  will  reproduce  the  vesicular  murmur.  As 
very  pronounced  lesions  are  associated  with  the  atelectasis,  obviously 
the  symptomatology  will  be  very  much  influenced  by  them.  An  im- 
portant complication  arises  from  the  collapse  of  lobules  ;  the  pulmo- 
nary circulation  is  obstructed,  the  blood  accumulates  on  the  right  side, 
the  cavities  dilate,  the  venous  system  is  abnormally  full,  and  the  ar- 
terial system  is  ischsemic.     The  results  of  this  state  of  things  are,  there 


ATELECTASIS.  335 

are  venous  stasis  and  oedema,  the  pulse  is  small,  the  urine  scanty  and 
high-colored,  and  the  skin  pale  and  relaxed. 

Course,  Duration,  and  Termination.  —  The  course  of  atelectasis  is 
that  of  the  malady  associated  with  it.  The  congenital  form,  if  limited 
in  extent  and  not  associated  with  a  patulous  condition  of  the  foramen 
ovale,  may  get  well.  If,  however,  it  is  extensive,  and  especially  if  the 
cardiac  anomaly  exist,  life  will  continue  feebly  for  a  short  period,  and 
death  occur,  frequently  in  convulsions.  The  acquired  condition,  when 
associated  with  capillary  bronchitis  and  catarrhal  pneumonia,  pursues 
two  directions  :  imperfect  recovery  with  damaged  lungs,  these  organs 
becoming  emphysematous  ;  caseous  pneumonia  and  phthisis.  The  du- 
ration, therefore,  becomes  indefinite,  and  the  termination  that  of  the 
associated  disease.  Acute  cases  terminating  fatally  rarely  continue 
longer  than  one  week. 

Diagnosis.  —  Atelectasis  is  to  be  distinguished  from  bronchitis, 
pneumonia,  and  effusions  in  the  thorax.  As  atelectasis  is  usually  as- 
sociated with  bronchitis,  the  distinction  will  rest  on  the  evidences  of 
consolidation  of  the  lung,  which  are  not  present  in  bronchitis.  There 
are  no  real  differences  between  atelectasis  and  catarrhal  pneumonia, 
since  atelectasis  occurs  more  or  less  in  the  former  ;  hence  the  distinc- 
tion must  rest  on  the  course  and  behavior,  on  the  locality,  and  the 
difficulty  of  breathing  with  retraction  of  the  ribs,  which  occurs  in 
atelectasis  and  not  in  catarrhal  pneumonia.  From  croupous  pneumo- 
nia atelectasis  is  distinguished  by  these  symptoms,  which  are  peculiar 
to  pneumonia  :  localized  pain,  initial  chill,  high  temperature,  crepitant 
rdles,  crisis — and  do  not  occur  in  atelectasis. 

Treatment. — In  the  congenital  disease,  the  child  should  be  made  to 
cry  vigorously,  or  the  lungs  should  be  well  expanded  by  an  efficient 
and  careful  inflation  with  condensed  air — an  ordinary -fire  bellows  will 
suffice.  The  chest  should  be  irritated  with  mustard  and  tincture  of 
iodine,  the  great  delicacy  of  an  infant's  skin  being  regarded.  Re- 
spiratory stimulants  are  very  useful.  Belladonna  stands  first,  next 
arsenic.  Suitable  nourishment  must  be  given,  and  stimulants  should 
also  be  freely  but  carefully  administered.  In  the  treatment  of  the 
acquired  disease,  the  accompanying  bronchitis  is  the  point  to  which 
attention  must  be  directed.  The  author  has  witnessed  such  important 
results-  from  the  use  of  iodide  and  carbonate  of  ammonium,  that  he 
must  repeat  his  recommendation  of  them.  They  should  be  given  in 
small  doses  frequently  repeated.  By  increasing  the  flow  of  serum  and 
lessening  the  viscidity  of  the  tough  secretion  which  occludes  the  ter- 
minal bronchi,  the  access  of  air  is  again  secured  to  the  alveoli.  Stim- 
ulants to  the  respiratory  function  are  equally  necessary  as  in  the  con- 
genital form.  Belladonna,  or,  preferably,  atropia  {-^-^  grain  ter  m 
die),  turpentine,  eucalyptol,  copaiba,  are  very  valuable  remedies  for 
this  purpose.  If  the  symptoms  are  urgent,  emetics  must  be  used  to 
25 


386  DISEASES  OF  THE  EESPIRATORY  ORGANS.   - 

clear  the  tubes,  of  which  the  most  effective  are  apomorphia,  subsul- 
phate  of  mercury,  and  ipecac.  If  the  strength  is  reduced,  or  if  the 
disorder  has  occurred  in  a  strumous  or  rachitic  subject,  quinia,  arsenic, 
iron  (syrup,  ferri  iodidi,  3  j  t&'H'  in  die),  and  cod-liver  oil,  are  very  ne- 
cessary and  useful.  Inhalations  of  compressed  air  should  be  prac- 
ticed as  soon  as  the  condition  of  the  patient  will  warrant  it.  Inhalations 
of  turpentine-fumes  and  of  the  vapor  of  iodine  are  very  efficient  appli- 
cations to  remove  lingering  bronchial  lesions. 


EMPHYSEMA  OF  THE  LUNGS. 

Definition. — As  eynphysema  means  an  infiltration  of  the  connective 
tissue  with  air,  certain  adjectives  are  necessary  to  define  the  position. 
Pulmonary  emphysema  is  the  form  of  disease  meant  here.  A  general 
emphysema  of  the  connective  tissue  of  the  body  is  produced  when  a 
fractured  rib,  puncturing  the  lung,  permits  the  air  to  pass  through  the 
injured  pleura  into  the  connective  tissue.  The  subject  has  been  much 
confused  by  the  variety  of  terms  employed  in  explanation  of  the  char- 
acteristics of  the  disease.  There  are  two  varieties,  as  regards  the  part 
of  the  lung  affected  :  the  vesicular  and  the  interlobular ;  the  former 
meaning  alveolar  emphysema,  the  latter  meaning  the  presence  of  air 
in  the  space  between  the  lobules  of  the  lungs  and  underneath  the  pul- 
monary pleura,  whence  the  terms  interlobular  em,physema,  sub-pleural 
emphyse'ina.  When  the  disease  occurs  as  an  idiopathic  and  indepen- 
dent malady,  it  is  known  as  substantive  emphysem,a  ;  when  developed 
because  of  another  malady,  as,  for  example,  the  dilatation  of  the  alveoli 
which  occurs  because  of  atelectasis,  it  is  known  as  vicarious  emphy- 
sema. 

Causes. — There  is  a  type  of  lung,  transmitted  by  heredity,  which 
is  peculiarly  liable  to  emphysema.  The  alveoli  are  relatively  too 
large  and  their  walls  thin ;  the  connective  tissue  too  largely  devel- 
oped ;  the  vascular  supply  is  insufficient ;  the  chest  is  deep,  and  the 
heart  lies  lower  than  is  normal ;  and  the  muscles  of  respiration  are  thin 
and  rather  weak.  Males  are  more  liable  than  females,  because  more 
exposed  to  the  conditions  exciting  the  malady.  It  is  said,  but  this 
statement  must  be  regarded  as  doubtful,  that  musicians  blowing  wind- 
instruments  are  apt  to  suffer  from  it.  Various  injuries  and  diseases 
of  the  chest  which  limit  the  movements  of  the  lungs,  as  curvature  of 
the  spine,  pleural  adhesions,  hydrothorax,  tumors,  etc.,  are  supposed  to 
produce  it.  Vicarious  emphysema  is  especially  due  to  attacks  of 
capillary  bronchitis  and  atelectasis  in  youth  and  early  manhood,  or 
succeeds  to  whooping-cough  and  measles  for  the  same  reason  that 
bronchitis  has  led  to  collapse  of  lobules,  and  consequent  emphysema 
of  those  not  collapsed.  All  of  the  causes  and  conditions  producing 
capillary  bronchitis  are  therefore  concerned  in  the  production  of  em- 


EMPHYSEMA  OF  THE  LUNGS.  387 

physema.  Interlobular  and  sub-pleural  emphysema  are  caused  by  rup- 
ture of  acini,  usually  by  such  mechanical  violence  as  severe  coughing, 
but  there  is  necessary  to  this  result  probably  a  weakness  of  the  part 
yielding  to  such  force.  Various  theories  have  been  proposed  to  ac- 
count for  the  production  of  emphysema  :  they  may  be  referred  to  two 
groups — inspiratory  and  expii-atory.  As,  however,  nutritive  disturb- 
ances exist  in  many  cases,  emphysema  is  produced  in  them  by  causes 
which  would  not  affect  healthy  lungs.  This  form  or  type  of  structure, 
which  is  distinctly  hereditary,  has  been  referred  to  above.  In  addi- 
tion to  these  changes,  Freund  explains  the  production  of  emphysema 
by  a  theory  which  supposes  the  thorax  to  be  in  a  condition  of  fixed 
dilatation  by  alterations  in  the  costal  cartilages.  Although  this  state 
of  the  thorax  may  sometimes  be  a  cause  of  emphysema,  it  can  not  be 
so  frequently.  That  structural  changes  are  important  factors  in  the 
production  of  emphysema  is  certainly  true  ;  but  that  the  respiratory 
acts  of  inspiration  and  expiration  have  also  much  influence  can  not  be 
doubted.  A  certain  proportion  of  cases  of  vicarious  emphysema  are 
produced  on  Williams's  theory  of  negative  inspiratory  pressure  ;  that 
is,  the  alveoli  appended  to  unobstructed  bronchi  dilate  in  consequence 
of  the  increased  pressure  due  to  the  obstruction  and  disuse  of  many 
tubes.  If  there  exist  an  hereditary  change  in  the  structure  of  the 
alveoli,  this  increased  pressure  causes  them  to  yield  permanently  and 
lose  their  elasticity.  If  the  inspiratory  pressure  is  thus  increased,  i.  e., 
by  the  obstruction  to  many  bronchi  throwing  a  larger  volume  of  air 
and  higher  pressure  on  those  admitting  air  freely,  and  the  expiratory 
pressure  is  lessened,  there  will  occur  emphysema  by  atrophy  of  the 
alveolar  tissue — the  theory  of  ISTiemeyer.  A  large  proportion  of  cases 
are  produced  undoubtedly  hj  forced  expiration.  In  the  act  of  cough- 
ing, the  glottis  being  closed,  the  expiratory  pressure  is  certainly  very 
great,  and  all  the  more  in  the  unobstructed  lobules,  because  so  many 
are  closed  and  are  in  the  atelectatic  state,  throwing  the  whole  force  of 
expiration  on  a  less  number  of  lobules.  The  result  is  that  the  alveoli 
yield  in  those  parts  of  the  chest  not  protected  by  bony  walls,  at  the 
apex,  and  toward  the  root,  at  the  anterior  border,  in  those  situations 
where  the  emphysematous  condition  is  most  decided. 

Pathological  Anatomy. — Enlargement  of  the  lungs  is  not  always 
found  as  expected  ;  adhesions  may  prevent  the  anterior  borders  coming 
forward  to  the  median  line,  or  the  lungs  may  be  actually  smaller  than 
normal  by  the  collapse  of  many  lobules,  the  occurrence  of  interstitial 
pneumonia,  and  the  contraction  of  the  connective  tissue.  On  the 
other  hand,  the  lungs  may  fill  up  the  thorax,  cover  the  prsecordial 
space,  depress  the  heart,  and  lengthen  the  thorax  to  the  seventh  rib 
by  depression  of  the  diaphragm.  When  the  emphysematous  lungs 
are  removed  from  the  thorax  they  do  not  collapse,  and  remain  full, 
especially  if  the  bronchi  are  swollen  and   filled  with  viscid  mucus. 


388  DISEASES   OF   THE   RESPIRATORY   ORGANS. 

which  will  prevent  the  egress  of  air.  The  situation  of  the  emphy- 
sematous portions  will  depend  on  the  form.  In  those  cases  due  to 
heightened  expii-atory  pressure,  the  force  is  expended  on  the  apex  and 
anterior  border,  and  hence  here  will  be  found  the  characteristic 
changes.  In  vicarious  emphysema,  due  especially  to  broncho-pneumo- 
nia, the  altered  portions  will  exist  more  widely — at  the  apex,  the  ante- 
rior border,  and  along  the  diaphragm,  or  they  may  be  very  irregularly 
distributed  about  the  atelectatic  points.  The  appearance  of  a  lung 
affected  with  emphysema  is  peculiar  :  it  is  of  a  pale-red  color,  the  en- 
larged lobules  are  little  sacs  or  bladders,  not  larger  than  from  the  size 
of  a  pin's-head  up  to  that  of  a  pea,  but  by  the  breaking  down  of  the 
septa  between  them  a  number  may  coalesce,  forming  a  bladder  the 
size  of  a  walnut.  When  pressure  is  made,  the  elasticity  of  the  lung 
is  found  to  be  so  much  impaired  that  the  pits  made  disappear  slowly 
or  not  at  all.  The  tissue  of  the  lung  is  also  very  dry  and  anaemic,  and 
but  little  fluid  of  any  kind  exudes  from  it  on  section  ;  but  there  is 
much  pigment  deposited  in  small,  localized  collections,  and  traversing 
the  atrophied  tissue  in  lines,  the  remains  of  blood-vessels.  On  micro- 
scopical examination,  the  walls  of  the  acini  are  found  to  be  exceed- 
ingly thin  and  attenuated,  the  septa  broken  down  so  that  the  remains 
of  them  merely  project  into  the  infundibular  area,  or  disappear  en- 
tirely.* In  some  specimens,  the  intervening  connective  tissue  becomes 
hypertrophied,  so  that  the  walls  of  the  vesicles  appear  much  thick- 
ened. In  the  progress  of  the  atrophic  change,  the  septa  between  the 
lobules  breaking  down,  a  number  of  acini  are  thus  converted  into  a 
large  one.  The  blood-vessels  are  from  the  beginning  obstructed,  the 
red  corpuscles  pass  out  by  diapedesis,  and,  collected  in  groups,  form 
the  masses  of  pigment  already  mentioned,  or  the  blood-globules  re- 
tained by  the  arrest  of  the  current  and  obliteration  of  the  vessels  in 
front  form  a  fine  tracery  of  pigment.  The  continued  pressure  sets 
up  a  rapid  degeneration  of  the  vessel- walls,  and  they  ultimately  disap- 
pear by  absorption,  whence  it  happens  that  the  tissue  is  dry  and  blood- 
less. The  obstruction  to  the  pulmonary  circulation  is  ultimately  so 
great  that  the  pulmonary  artery  and  right  cavities  become  greatly 
distended.  Finally,  the  muscular  tissue  of  the  heart  undergoes  de- 
generation, granular  and  fatty.  The  distention  of  the  veins  leads  to 
widespread  venous  stasis — nutmeg-liver,  congested  kidneys,  and  albu- 
minuria, gastro-intestinal  hyperaemia  and  catarrh,  passive  congestion 
of  the  brain,  etc. 

Symptoms. — The  usual  history  of  cases  of  emphysema  is  the  occur- 
rence of  attacks  of  capillary  bronchitis,  catarrhal  pneumonia,  or  at 
least  of  severe  bronchitis  at  some  period  in  childhood,  after  which 
there  exists  a  great  susceptibility  to  colds  and  frequent  attacks  of 

*  Thierf elder,  "  Pathologische  Histologie,"  1.  Lieferung,  Tafel  vi. 


EMPHYSEMA  OF  THE  LUNGS.  389 

severe  catarrh  with  difficulty  of  breathing.  After  puberty  the  diffi- 
culty of  breathing  is  found  to  be  more  decided ;  bronchial  catarrh  is 
not  then  a  matter  of  cold  weather  and  attacks  of  acute  cold,  but  is 
constantly  present.  In  other  cases,  after  whooping-cough,  or  measles, 
a  troublesome  cough,  bronchial  catarrh,  and  shortness  of  breath  come 
on,  and  steadily  increase.  If  such  attacks  have  occurred  in  youth,  by 
the  time  of  puberty  the  emphysema  is  pronounced,  and  the  chest  has 
assumed  the  peculiar  "  barrel-shape,"  characteristic  of  this  disease.  In 
still  another  group  of  cases,  the  onset  is  gradual,  and  the  emphysema 
is  the  outgrowth  of  years  of  bronchial  catarrh,  the  fully  developed 
emphysema  not  being  attained  until  the  middle  or  after  period  of 
life.  In  which  mode  soever  emphysema  manifests  itself,  the  diffi- 
culty of  breathing  is  the  most  pronounced  symptom.  In  all  attempts 
at  active  exercise,  mounting  stairways,  ascending  heights,  etc.,  the 
breathing  is  embarrassed.  Even  before  the  patient  is  conscious  of  his 
pulmonary  defects  in  this  direction,  a  good  observer  will  note  the  fre- 
quency and  imperfect  expansion  of  the  thorax.  The  shortness  of 
breathing  is  dependent  on  several  factors  :  the  diminution  in  the  num- 
ber of  capillaries  has  an  effect  in  this  way  by  the  lessening,  which  the 
loss  of  vessels  involves,  of  the  oxygenation  of  the  blood,  so  that  in- 
creasing frequency  of  respiration  is  compensatory  of  this  deficiency. 
Again,  depression  of  the  diaphragm  renders  additional  efforts  on  the 
part  of  the  inspiratory  muscles  necessary,  and  hence  this  adds  to  the 
difficulty  of  carrying  on  respiration.  More  important  than  these  is  the 
loss  of  the  elasticity  of  the  lung,  which  requires  that  the  muscles  of 
expiration  shall  take  up  the  labor  of  expelling  the  air,  which  they 
accomplish  slowly  and  with  great  effort.  This  expiratory  insuffi- 
ciency involves  another  difficulty — the  residual  air  in  the  acini  is  not 
displaced,  and  hence  can  not  furnish  oxygen  to  the  blood.  The  con- 
currence of  these  several  factors  produces  the  most  obvious  objective 
symptom  in  emphysema — the  embarrassed  respiration.  Both  inspira- 
tion and  expiration  are  embarrassed  ;  all  the  muscles,  auxiliary  as  well 
as  ordinary,  are  engaged  in  inspiration  and  expiration,  but  the  move- 
ments of  the  chest  are  very  slight  notwithstanding  the  labor,  and  a 
constant  and  distressing  sense  of  the  need  of  air  is  experienced ;  the 
cervical  muscles  are  rigid  and  prominent,  the  head  erect  and  forward 
to  permit  the  easy  entrance  of  air  and  to  facilitate  the  action  of  the 
muscles  ;  the  shoulders  elevated ;  the  veins  of  the  neck  enlarged  and 
dilated,  and  the  face  more  or  less  cyanosed.  A  peculiar  configuration 
of  the  chest  is  brought  about  by  emphysema,  which  has  existed  for 
some  time  in  young  subjects.  The  chest  becomes  round  ;  the  inter- 
costal spaces  wider  ;  the  vertical  diameter  elongated.  As  the  emphy- 
sema may  be  limited  to  one  part,  the  changes  in  the  shape  of  the 
chest  will  correspond.  The  departure  from  the  normal  consists  in  a 
circumscribed  prominence  more  frequently  on  the  left  than  the  right 


390  DISEASES   OF    THE   RESPIRATORY   ORGAXS. 

side  ;  above  the  clavicle,  or  between  the  clavicle  and  nipple,  or,  during 
coughing,  the  lung  pushes  the  parietes  of  the  chest  forward  at  these 
points,  producing  a  soft,  elastic,  and  resonant  swelling.  The  physical 
signs  are  very  instructive.  On  inspection,  the  character  of  the  respira- 
tion, the  movements  of  the  accessory  muscles,  and  the  extremely  small 
excursions  of  the  thorax  in  breathing  are  readily  ascertained.  On  pal- 
pation, the  vocal  fremitus  is  diminished,  the  apical  impulse  is  feeble, 
and  the  epigastric  pulsations  are  increased.  The  heart  is  found  to 
lie  lower  down  than  in  the  normal  thorax,  and  the  liver  is  also  pushed 
lower,  both  due  to  the  enlargement  of  the  lungs  in  the  vertical  diam- 
eter. On  percussion,  the  sonority  is  increased  over  all  the  emphysema- 
tous portions,  and,  when  the  whole  lung  is  involved,  extends  dowm  to 
the  seventh  or  eighth  rib  in  front,  and  behind  to  the  twelfth  rib  in 
extreme  cases.  The  hepatic  dullness  may  not  begin  until  the  inferior 
margin  of  the  ribs  is  reached,  and  even  when  hypertrophy  exists  the 
area  of  cardiac  dullness  is  much  narrowed  and  may  not  exist  at  all 
when  the  emphysema  is  extreme.  On  auscultation  over  all  parts  re- 
turning a  resonant  percussion-note,  the  vesicular  murmur  is  weakened, 
and  may  entirely  disappear  over  the  lungs  ;  and  the  bronchial  sounds, 
which  are  audible  at  the  root  of  the  lungs  posteriorly  in  the  normal 
state,  may  also  disappear.  In  other  cases,  the  vesicular  murmur, 
whether  enfeebled  or  not,  is  changed  in  character  ;  on  inspiration  it 
becomes  rough,  rude,  sibilant  or  crackling,  due  to  the  entrance  of  air 
into  the  dilated  and  inelastic  lobules,  and  expiration  is  prolonged  and 
rough  from  the  same  cause.  Expiration  is  usually  inaudible,  but  an 
expiratory  sound  may  be  due  to  an  accompanying  bronchitis,  to  nar- 
rowing of  the  bronchioles  by  swelling  of  the  mucous  membrane, 
whence  the  sound  has  a  rather  sibilant  character.  The  accompanying 
bronchitis,  which  is  usually  quite  extensive,  produces  various  moist 
sounds — sub-crepitant,  mucous,  and  sub-mucoas  rctles,  which  are  not 
necessary  to  emphysema.  The  sounds  of  the  heart  audible  in  the 
mitral  and  aortic  area  are  in  emphysema  less  distinct  than  in  the  nor- 
mal state,  while  in  the  pulmonary  and  tricuspid  area  they  are  well 
defined,  the  pulmonary  second  sound  being  sharply  accentuated. 

Course,  Duration,  and  Termination. — Emphysema  is  an  essentially 
chronic  malady.  Beginning  often  years  before  any  great  difficulty  of 
breathing  is  manifest,  it  pursues  a  course  which  iii  its  mildest  form 
may  continue  during  an  ordinary  lifetime.  The  least  extensive  cases 
may  continue  with  little  interference  in  the  duties  of  life  for  many 
years,  but  the  case  is  far  different  with  those  examples  of  emphy- 
sema occupying  a  large  part  of  both  lungs.  In  a  pronounced  case, 
beginning  in  one  of  the  modes  already  described,  there  are  constant 
difficulty  of  breathing,  and  cough  and  expectoration  due  to  an,  attend- 
ant bronchitis.  On  taking  a  bronchial  cold,  to  which  they  are  ex- 
tremely liable,  or  on  making  some  sudden  muscular  effort,  the  diffi- 


EMPHYSEMA  OF  THE  LUXGS.  391 

culty  of  breathing  is  greatly  increased,  they  labor  to  get  breath,  are 
blue  in  the  face,  sweating  with  their  exertions,  and  unable  to  lie  down. 
After  some  hours,  or  a  day  or  two,  the  paroxysm  subsides,  and  they 
are  back  again  in  the  former  condition,  except  each  attack  increases  a 
little  the  existing  mischief,  the  breathing  is  a  little  more  embarrassed, 
and  there  are  more  cough  and  expectoration.  The  paroxysms  of  asth- 
matic difficulty  of  breathing  increase  in  number  and  frequency,  until 
after  some  years  there  is  no  period  of  partial  relief.  Meanwhile,  the 
obstacles  to  the  pulmonary  circulation  increase  :  dilatation  of  the  right 
cavities  of  the  heart  and  stasis  in  the  venous  system  occur  ;  the  liver 
swells  with  venous  hypersemia  ;  the  gastro-intestinal  mucous  mem- 
bi-ane  also  is  hypersemic,  and  is  affected  with  catarrh  ;  the  liver  is 
congested,  and  the  urine  becomes  albuminous.  General  dropsy  now 
comes  on,  fluid  accumulates  in  the  peritoneal  cavity  also,  but  to  a  less 
extent  in  the  pleura.  The  presence  of  fluid  in  the  two  cavities  adds 
to  the  difficulty  of  respiration,  and  now  the  patient  can  get  breath 
only  as  he  sits  up,  leaning  somewhat  forward.  This  position  increases 
the  accumulation  of  fluid  in  the  legs,  which  become  blue,  cold,  and 
very  painful ;  the  skin  yields,  blisters  form,  and,  giving  way,  an  ulcer 
is  established  from  which  serum  continuously  exudes.  Such  is  the 
course  of  a  well-defined  case.  Although  all  are  not  so  severe,  yet 
when  emphysema  occurs  in  an  adult  it  is  a  permanent  condition.  It 
is  probable  that  a  slight  amount  of  emphysema  in  a  child  may  get 
well,  but  usually  the  first  changes  in  childhood  are  the  initial  of  a  long 
series,  and  continue.  Death  may  be  due  to  the  rupture  of  some  of  the 
dilated  cells  and  the  formation  of  an  extensive  interlobular  and  sub- 
pleural  emphysema.  The  termination  is  often  by  some  intercurrent 
disease,  as  catarrhal  or  croupous  pneumonia,  cerebral  haemorrhage,  or 
paralysis  of  the  heart.  Notwithstanding  the  unpromising  nature  of 
the  disease,  all  do  not  proceed  regularly  from  bad  to  worse.  Periods 
of  improvement  may  take  place,  and  the  difficulty  of  breathing  almost 
disappears,  to  return  again,  however,  on  the  occurrence  of  a  bronchial 
attack  or  some  other  disturbance.  The  cases  are,  as  a  rule,  more  se- 
vere in  winter  than  in  summer. 

Diagnosis. — The  diseases  with  which  emphysema  may  be  con- 
founded are  bronchitis,  bronchial  asthma,  catarrhal  pneumonia,  pneu- 
mothorax, aneurism  of  the  arch  of  the  aorta,  and  cardiac  diseases,  with 
spasmodic  difficulty  of  breathing.  From  bronchitis,  it  is  distinguished 
by  the  presence  of  those  signs  characteristic  of  emphysema,  as  diffi- 
culty of  breathing,  increased  sonority  of  the  chest,  changes  in  the 
shape  and  size  of  the  thorax,  and  by  the  disturbances  of  the  circula- 
tion and  dropsy  ;  from  bronchial  or  spasmodic  asthma,  by  the  fact 
that  in  the  latter  there  are  no  alterations  of  the  chest,  and  the  diffi- 
culty of  breathing  is  occasional  and  spasmodic  entirely  ;  from  catar- 
rhal pneumonia,  by  the  history,  by  the  localization  of  the  affection,  by 


392  DISEASES   OF   THE   RESPIRATORY   ORGANS. 

the  changes  in  the  chest,  and  by  the  subsequent  course  ;  from  pneu- 
mothorax, by  these  considerations  :  pneumothorax  is  sudden,  almost 
always  unilateral,  the  chest  much  distended,  the  intercostal  spaces 
prominent,  the  heart  is  displaced  to  the  other  side,  succussion  is  pres- 
ent if  there  is  fluid,  which  is  usually  the  case.  In  aneurism  there  is 
dullness  instead  of  increased  sonority  over  the  site  of  the  aneurism, 
and  no  change  elsewhere,  and  the  difficulty  of  breathing  is  due  to  pa- 
ralysis of  the  vocal  cord,  which  may  be  seen,  and  to  pressure  on  nerve- 
trunks.  In  heart-disease  the  area  of  dullness  is  not  only  present  but 
usually  increased,  and  the  apex-beat  is  normal  or  increased,  while  the 
form  of  the  chest  and  the  sonority  are  not  affected. 

Treatment. — As  we  have  to  deal  with  an  incurable  disease,  our 
treatment  must  be  largely  palliative.  For  the  asthmatic  attacks  there 
is  no  remedy  so  efficient  as  the  subcutaneous  injection  of  morphia  and 
atropia  {^  morphia  and  yl^  atropia).  Care  must  be  exercised  lest  the 
morphia-habit  be  formed,  as  it  is  apt  to  be  under  these  circumstances, 
and  hence  the  injections  should  always  be  practiced  by  the  physi- 
cian, and  reserved  for  occasions  of  great  distress.  A  single  injec- 
tion may  arrest  a  paroxysm,  but  the  dose  may  be  repeated  as  neces- 
sary, rarely  more  frequently  than  once  in  six  hours.  Next  to  the 
injection  of  morphia,  most  relief  is  afforded  by  full  doses  of  iodide  of 
potassium  alone,  or  combined  with  the  bromide.  From  fifteen  to 
twenty  grains  of  the  iodide,  and  forty  grains  of  the  bromide,  every 
two,  three,  or  four  hours,  according  to  the  urgency,  may  be  prescribed. 
Chloral,  which  affords  great  relief,  is  very  unsafe  in  old  cases  with 
dilated  right  cavities  ;  if  given  under  any  circumstances,  it  should  be 
combined  with  morphia  and  atropia  to  prevent  the  depressing  effect  on 
the  heart.  A  combination  of  morphia,  chloral,  and  atropia  is  an  ex- 
ceedingly serviceable  combination  for  the  relief  of  the  difficult  breath- 
ing. Besides  these  agents,  narcotic  fumigation  may  be  practiced. 
Pastils  of  belladonna,  stramonium,  tobacco,  opium,  eucalyptus,  etc., 
may  be  burned,  and  the  fumes  inhaled.  Such  pastils  are  always 
much  used  by  these  sufferers,  since  they  procure  in  this  way  ready  and 
considerable  relief.  As  the  accompanying  bronchitis  is  an  important 
element  in  these  cases,  measures  are  necessary  to  relieve  it.  The  best 
results  are  obtained  from  copaiba,  turpentine,  and  eucalyptol,  given  in 
conjunction  with  the  iodide  of  ammonium.  Excellent  results  are  ob- 
tained from  the  combined  administration  of  iodide  of  ammonium  and 
arsenic,  continued  for  some  time.  It  is  well  known  that  arsenic  increases 
the  depth  and  volume  of  the  respiration  and  promotes  the  nutrition  of 
the  lung,  and  the  iodide  is  an  effective  remedy  for  the  bronchitis.  In 
these  facts  we  have  an  explanation  of  the  utility  of  the  combination. 
When  the  bronchial  secretions  are  insufficient,  small  doses  of  tartrate 
of  antimony  are  very  useful,  and  give  great  relief.  Just  that  quantity 
which  induces  a  little  sqeamishness,  and  no  more,  is  the  quantity  re- 


EMPHYSEMA  OF  THE  LUNGS.  393 

quired  for  this  purpose.  Atropia  is  a  remedy  of  great  power,  and  has 
an  influence  over  the  lung,  increasing  the  respiration  and  promoting 
the  nutrition  of  the  organ.  It  may  distress  if  there  is  a  lack  of  bron- 
chial secretion,  but  usually  the  opposite  state  obtains,  and  consequently 
atropia  can  be  given,  as  it  ought  to  be,  under  these  circumstances,  in 
small  doses  twice  a  day  for  a  long  period.  Of  all  the  means  hitherto 
proposed  for  the  relief  of  emphysema,  nothing  has  approached  com- 
pressed air  in  effectiveness.  Indeed,  this  is  the  only  scientific  remedy 
which  has  as  yet  been  brought  forward  for  the  treatment  of  emphy- 
sema. The  chamber  into  which  air  is  pumped  until  a  pressure  of  one 
and  a  half  to  two  atmospheres  is  obtained  is  the  best  arrangement, 
but  unfortunately  they  are  available  but  in  a  few  places.  The  port- 
able apparatus  of  Waldenburg  is  convenient,  easily  managed,  and  pro- 
duces good  results.  The  object  of  compressed  air  is  to  relieve  the 
breathing  by  supplying  more  oxygen,  and  it  effects  an  equalization  of 
the  blood  in  the  two  systems  by  redistributing  the  pressure.  By  re- 
tarding the  breathing  and  the  action  of  the  heart,  the  contractions  are 
firmer,  and  the  cavities  are  better  emptied.  The  improved  condition 
of  the  blood,  the  result  of  a  better  supply  of  oxygen  and  increased 
excretion  of  carbonic  acid,  induces  a  better  state  of  digestion  and  as- 
similation. By  breathing  compressed  air,  the  pressure  is  transferred 
from  the  venous  to  the  arterial  system,  and  while  the  amount  of  blood 
on  the  right  side  is  diminished,  on  the  left  it  is  increased.  The  good 
effects  of  breathing  compressed  air  are  enhanced  by  expiration  into 
rarefied  air,  which  of  course  has  the  effect  to  draw  the  blood  into  the 
lungs.  "  Expiration  into  rarefied  air  is  the  specific  mechanical  anti- 
dote to  emphysema."  *  The  inhalation  of  compressed  air  or  of  oxy- 
gen may  be  used  as  a  palliative  to  relieve  the  attacks  of  spasmodic 
difficulty  of  breathing. 

The  treatment  of  the  dropsy  requires  a  nice  adjustment  of  means  to 
the  object.  Much  can  be  accomplished  by  acting  on  the  skin  and  kid- 
neys. If  the  heart  will  bear  it,  pilocarpine  may  be  employed  to  act  on 
the  skin.  Hydragogue  cathartics  can  be  given  at  the  same  time,  of 
which  the  pulv.  jalapse  comp,  is  best.  A  teaspoonful  or  two  should  be 
taken  in  the  early  morning,  and  pilocarpine  in  the  afternoon.  If  the 
desired  results  can  not  be  thus  attained,  free  diuresis  may  be  attempted 
while  the  hydragogue  is  also  administered.  Basham's  mixture  is  an 
excellent  combination,  containing  as  it  does  a  chalybeate  with  a  saline. 
Niemeyer's  prescription  of  vinegar  of  squill,  with  bicarbonate  of  potas- 
sa — thus  forming  acetate  of  potassa — is  a  good  diuretic.  There  is  no 
more  certain  diuretic  than  bitartrate  of  potassa,  and  it  may  be  com- 
bined with  infusion  of  juniper  and  squill.  A  weak  solution  of  cream 
of  tartar  may  be  drunk  ad  libitum.     Infusion  of  digitalis  may  also  be 

*  "Die  pneumatische  Behandlung,"  etc.,  Dr.  L.  Waldenburg,  Hirschwald,  Berlin,  1875, 
p.  302. 


39J:  DISEASES   OF    THE   RESPIRATORY   ORGANS. 

given  ;  but  as  so  much  obstruction  exists  in  the  lung,  and  as  there  is 
also  ischfemia  of  the  arterial  system,  its  use  is  doubtful. 


GANGRENE   OF  THE   LUNG. 

Definition. —  Gangrene  is  the  same  morbid  process,  whether  occur- 
rincj  in  the  luns:  or  elsewhere.  Gangrene  of  the  lung,  therefore,  means 
the  death  and  decomposition  of  a  greater  or  less  portion  of  the  lung- 
tissue. 

Causes. — Sex  exercises  an  important  influence,  since  somewhat  more 
than  two  thirds  of  the  cases  occur  in  men.  Although  it  may  occur  at 
any  age,  it  is  more  common  from  puberty  to  middle  life,  "A  lowered 
condition  of  the  yital  forces,  such  as  is  jjroduced  by  abject  poverty  and 
its  attendant  miseries,  seems  necessary  to  the  result.  Interruptions  to 
the  blood-supplv,  as  elsewhere,  may  induce  gangrene.  Thus  it  occurs 
in  cases  of  pneumonia,  hemorrhagic  infarctions,  catarrhal  pneumonia, 
etc.  ;  but  a  depressed  bodily  state  is  necessary,  such  as  exists  in  di-unk- 
ards  who  are  ill  fed  and  exposed  to  cold  and  wet.  Gangrene  may  be 
due  to  the  so-called  blood-diseases — as  typhus,  diabetes,  small-pox, 
measles,  etc. — but  a  low  state  of  the  tissues  or  a  depressing  cachexia 
must  coincide,  the  lung  becoming  the  seat  of  the  morbid  process  be- 
cause invited  by  a  local  malady,  such  as  pneumonia.  The  deposit  in 
the  lung  of  septic  and  decomposing  materials,  as  septic  or  infective 
emboli,  will  set  up  a  destructive  inflammation  terminatmg  in  gangrene. 
Putrefactive  decomposition  in  the  neighborhood  of  the  lungs,  the 
penetration  of  the  organ  by  cancer-masses,  or  the  lodgment  of  foreign 
bodies,  may  give  rise  to  a  gangrenous  inflammation.  Lastly,  gangrene 
may  be  due  to  traumatism,  or  to  penetrating  wounds  of  the  chest. 

Pathological  Anatomy. — Gangrene  may  attack  any  part  of  the  lung, 
but  the  upper  lobe  is  more  often  the  seat  of  it  than  the  inferior.  It 
occiirs  iu  two  forms,  of  circumscribed,  of  diffused — the  former  being 
well  defined  and  strictly  limited,  the  other  not  separated  by  any  defined 
border,  but  spreading  into  the  surrounding  limg-tissue.  The  circum- 
scribed form  attacks  by  preference  the  outer  portion  of  the  lung,  and 
may  or  may  not  include  the  plem-a.  There  may  be  several  of  the  gan- 
grenous spots,  which  vary  in  size  from  a  pea  to  an  orange,  or  even 
larger,  and  they  occur  rather  more  frequently  in  the  right  lung.  The 
borders  are  clearly  marked,  the  surrounding  tissue  being  hepatized  or 
cedematous.  According  to  the  time  at  which  the  masses  are  examined, 
they  are  firm,  dry,  almost  black  or  soft,  difliuent,  greenish,  or  brown- 
ish, decomposing  and  offensive  masses  traversed  by  large  vessels  not 
destroyed,  and  by  bronchi,  opened  by  ulceration,  through  which  the 
liquid  and  softened  debris  are  discharging.  Gradually  sloughing  off 
after  evacuation  by  the  bronchi,  there  may  be  an  attempt  at  repair, 
the  spread  of  the  decomposition  being  prevented  by  the  formation  of 


GANGRENE   OF  THE   LUNG.  395 

a  dense,  tough,  and  rather  hyperjemic  connective-tissue  membrane.  A 
complete  recovery  can  only  occur  when  the  gangrenous  mass  is  small 
and  communicates  with  a  small  bronchus.  The  membrane  lining  the 
cavity,  formed  as  just  described,  pours  out  a  quantity  of  ichorous  pus, 
which  serves  to  spread  the  morbid  process.  When  the  cavity  is  small 
enough  to  close  and  heal,  granulations  are  thrown  out,  the  walls  ap- 
proximate, and  healing  takes  place,  a  cicatrix  remaining.  The  ichor- 
ous pus  poured  out  from  the  so-called  pyogenic  membrane  sets  up  a 
destructive  inflammation  of  the  bronchial  mucous  membrane,  which 
softens  and  is  detached,  and  excites  attacks  in  the  dependent  parts  of 
the  lungs  of  broncho-pneumonia,  which  pursue  the  same  course.  If 
situated  at  the  periphery  of  the  lung  the  softening  may  involve  the 
pleura,  and  the  decomposing  materials  be  discharged  into  the  pleural 
cavity,  exciting  a  violent  pleuritis  and  a  pyopneumothorax,  if  a  bron- 
chus is  at  the  same  time  opened.  It  is  a  remarkable  fact  that  a  limit- 
ing pleuritis  may  confine  the  inflammation  to  a  small  extent  of  the 
membrane,  perforation  of  the  thorax  ultimately  ensue,  with  a  termina- 
tion in  recovery.  In  a  few  cases  the  pus  has  dissected  downward  along 
the  sheath  of  the  psoas  muscle  and  opened  externally  at  the  groin. 
The  diffused  form  may,  as  has  been  shown,  arise  from  the  circum- 
scribed by  an  extension  of  the  morbid  process  through  the  distribution 
of  the  ichorous  pus  from  a  gangrene  cavity.  But  the  diffused  form 
usually  has  its  origin  in  an  inflammation  proceeding  from  a  gangrenous 
cavity,  or  from  a  case  of  purulent  infiltration  of  pneumonia.  The  tis- 
sue affected  with  the  gangrenous  inflammation  rapidly  breaks  up  into 
shreds  of  decomposing  materials,  infiltrated  with  a  brownish  or  black- 
ish fetid  fluid,  and  the  morbid  process  spreads  into  the  surrounding 
tissue,  hepatized  and  oedematous,  without  any  defined  boundary.  In  a 
short  time  much  of  the  upper  lobe  may  be  in  a  gangrenous  state,  and 
the  whole  of  it,  indeed,  may  be  involved.  In  both  forms  the  spread 
of  the  gangrene  may  be  too  rapid  to  permit  the  vessels  to  be  closed, 
and  hence  there  may  be  formidable  or  fatal  hemorrhage.  Metastatic 
abscesses  may  form  in  various  organs,  from  infective  emboli  proceed- 
ing from  the  veins  of  the  gangrenous  parts. 

Symptoms. — Gangrene  of  the  lung  being  usually  a  secondary  dis- 
ease, the  symptoms  proper  to  the  gangrene  are  obscured  by  the  as- 
sociated malady  ;  and  there  are  great  variations  at  different  periods. 
Before  communication  is  established  with  a  bronchus,  when  the  diag- 
nosis is  rendered  certain  by  the  character  of  the  expectorated  matters, 
the  only  symptoms  are,  a  sudden  depression  of  the  powers  of  life, 
changes  in  the  character  of  the  existing  fever,  and  a  very  high  range 
of  temperature.  The  symptoms  become  characteristic  only  when  the 
sputa  contain  the  materials  of  the  gangrenous  decomposition.  The 
sputum  is  a  sanguinolent,  sanious,  or  sero-mucus  fluid,  of  brownish  dark- 
green,  or  even  blackish  tint,  having  a  horribly  fetid  odor,  compounded 


396  DISEASES   OF   THE   RESPIRATORY   ORGANS. 

of  decomposing  animal  matter  and  faeces,  and  so  sickening  that  the 
patient  himself  as  well  as  those  about  him  is  nauseated  by  it.  That 
the  odor  is  due  to  foul  gases  is  evident  from  the  fact  that  the  breath 
on  forced  expiration  is  full  of  the  odor,  and  the  sputa  allowed  to  stand 
cease  after  a  time  to  have  the  smell.  The  odor  may  precede  the  ex- 
pectoration, and  may  disappear  for  a  time,  to  reappear  again.  The 
sputa  on  standing  separate  into  three  distinct  layers  :  the  uppermost, 
frothy,  of  a  dark,  greenish-yellow  color,  is  composed  of  muco-pus 
chiefly;  the  middle  layer  is  sero-albuminous  and  translucent;  the  lowest 
layer  contains  a  sediment,  greenish  or  brownish  in  color,  with  yellow 
or  brownish  flakes  and  masses  of  decomposing  lung-tissue.  Again, 
the  sputa  may  be  made  up  largely  of  black  blood,  in  a  decomposing 
state  (Hertz).  Chemically,  the  sputa  have  an  alkaline  reaction,  and 
contain  valerianic  acid,  the  fat  acids,  leucin  and  tyrosin,  triple  phos- 
phate, and  other  products  of  decomposition.  During  the  process  of 
development  of  the  gangrene,  the  symptoms  indicate  the  existence  of 
a  grave  disorder.  TJie  elevation  of  temperature  may  be  very  consider- 
able, but  the  thermal  line  is  that  of  septicaemia  :  irregular  chills,  high 
fever,  and  profuse  sweats.  The  complexion  is  fawn-color,  livid,  the 
expression  anxious,  the  face  sunken,  the  skin  relaxed,  the  pulse  quick 
and  feeble,  and  the  respirations  are  hurried  and  catching.  There  is 
usually  severe  pain  in  the  side,  and  the  decubitus  is  toward  and  on  the 
affected  side.  There  is  an  incessant  and  very  painful  suppressed  cough. 
Copious  pulmonary  haemorrhage  may  and  usually  does  take  place, 
started  by  the  coughing.  The  fetid  expectoration  is  apt  to  be  swal- 
lowed, and  excites  by  its  presence  nausea,  vomiting,  and  diarrhoea,  but 
the  absorption  of  putrid  matters  and  the  congestion  of  the  portal  circu- 
lation will  also  cause  watery  and  fetid  stools.  The  operation  of  these 
causes  rapidly  exhausts  the  vital  powers,  and  the  patient  lapses  into  a 
condition  of  profound  adynamia.  The  physical  signs  are  such  as  per- 
tain to  changes  in  the  density  of  the  pulmonary  tissue.  On  percussion, 
the  sonority  of  the  chest  is  lessened  in  proportion  to  the  extent  of  the 
solidification,  but,  as  there  is  more  or  less  pulmonary  tissue  still  pervious 
to  air  about  the  gangrenous  portions,  the  dullness  has  somewhat  the 
tympanitic  quality.  On  auscultation,  coarse  rdles,  mucous  and  sub- 
mucous, are  audible,  and  there  are  bronchial  breath  and  bronchial  voice. 
After  the  softening  and  extrusion  of  the  gangrenous  portions,  the 
physical  signs  will  correspond,  and  the  symptoms  of  a  cavity  will  be 
present. 

Course,  Duration,  and  Termination. — The  course  of  the  disease  is  so 
largely  affected  by  the  morbid  condition  on  which  it  is  ingrafted  that 
no  defined  plan  can  be  laid  down.  The  circumscribed  form  is  slower  in 
development,  and  the  symptoms  are  less  formidable,  than  the  diffused, 
and  its  duration  is  therefore  longer.  In  those  cases  which  tend  to  cure 
by  the  extrusion  of  the  gangrenous  mass  through  a  bronchus,  or  by 


GANGRENE   OF   THE   LUNG.  397 

establishing  a  fistulous  communication  externally,  the  duration  is  pro- 
tracted, and  not  to  be  expressed  with  definiteness,  because  so  much 
depends  on  the  vital  resources,  and  on  the  size  of  the  gangrenous  patch. 
The  cases  of  partial  recovery  in  which  there  is  a  cavity  lined  by  a 
pyogenic  membrane  continue  for  months  ;  but  every  now  and  then 
fresh  inflammation  arises,  more  tissue  is  destroyed,  until  death  finally 
ensues.  The  usual  termination  is  in  death,  after  two  or  three  or  even 
six  weeks  of  the  circumscribed  form,  and  in  a  week  or  two  of  the  dif- 
fused form.  Certain  accidents  may  occur  which  will  materially  abbre- 
viate either,  as  haemorrhage,  perforation  of  the  pleura,  etc.  The  causes 
of  death  are  various — pleuritis,  peritonitis,  hasmorrhage,  exhaustion,  etc. 
Perforation  of  the  pleura  may  cause  death  by  the  intermediation  of 
pyopneumothorax,  sudden  distention  of  the  cavity,  severe  dyspnoea,  and 
collapse  ;  or  it  may  cause  a  fistulous  communication,  emphysema  of 
the  connective  tissue,  and  exhaustion,  the  fistula  discharging  ichorous 
serum  and  the  foul-smelling  products  of  gangrenous  decomposition. 
Perforation  of  the  diaphragm  and  purulent  peritonitis  may  be  a  cause 
of  death.     The  prognosis  is,  of  course,  exceedingly  grave. 

Diagnosis. — It  must  be  obvious  that  a  diagnosis  of  gangrene  of  the 
lung  is  not  possible  when  the  mass  affected  does  not  communicate  with 
a  bronchus.  Fetor  of  the  breath  is,  of  course,  the  first  indication,  but 
this  is  not  pathognomonic  by  any  means.  As  the  pus  in  cavities  and 
of  dilated  bronchi  may  by  decomposition  become  fetid,  and  as  bits  of 
decomposing  lung-tissue  are  cast  off  in  the  sputa,  fetor  of  the  sputa  as 
a  means  of  diagnosis  must  be  accepted  with  limitations.  The  diag- 
nosis, under  these  circumstances,  must  rest  largely  with  the  clinical 
history,  the  severity  of  the  symptoms,  and  the  duration.  Those  familiar 
with  the  character  of  the  odor  in  gangrene  will  recognize  its  penetrat- 
ing power  and  intensity,  as  compared  with  the  much  feebler  odor  in 
putrid  bronchitis  and  in  bronchiectasis.  All  of  the  symptoms  in  gan- 
grene of  the  lung  are  much  more  active  and  severe  than  are  those  of 
bronchitis.  In  gangrene,  further,  there  are  present  the  physical  signs 
of  pulmonary  disease,  which  are  absent  in  bronchitis.  The  differentia- 
tion of  fetid  sputa  from  a  cavity  in  phthisis,  from  gangrene,  is  more 
difficult,  but  the  greater  intensity  of  the  odor  in  the  latter  and  the  ap- 
pearance and  composition  of  the  sputa  will  serve  to  distinguish  between 
them  ;  but,  as  cavities  are  present,  the  history  and  behavior  of  the  two 
maladies  must  be  taken  into  consideration. 

Treatment. — To  maintain  the  powers  of  life  by  the  free  administra- 
tion of  spirits,  small  doses  of  opium  and  quinia,  and  such  aliment  as 
beef-juice,  egg-nog,  etc.,  is  the  leading  indication,  to  which  all  specific 
treatment  must  be  subordinated.  Excellent  results  have  been  obtained 
from  turpentine  (gtt.  v)  every  two  hours  ;  but  still  more  from  eucalyp- 
tol,  which  has  been  very  much  extolled  recently.  Eucaly'ptol  is  most 
easily  taken  in  perls  (tti,  v),  but  it  can  be  made  tolerable  in  an  emul- 


398  DISEASES   OF   THE   RESPIRATORY   ORGANS. 

sion.  Benzoic  acid,  thymol,  and  carbolic  acid,  especially  the  last 
named,  are  very  useful  in  correcting  fetor,  and  also  play  the  part  of 
antiseptics,  being  eliminated  largely  by  the  lungs.  Acetate  of  lead  is 
the  remedy  most  approved  by  Traube.  Inhalations  should  be  prac- 
ticed with  those  remedies,  such  as  iodine,  which  may  diffuse  by  vola- 
tilization, and  with  oxygen,  which  relieves  the  dyspnoea  and  improves 
the  blood.  Iodine,  or  the  tincture,  may  •  be  vaporized  by  a  gentle 
warmth,  and  the  fumes  gradually  introduced  into  the  air  the  patient 
is  breathing.  The  benzoate  of  soda,  or  of  ammonia,  should  be  intro- 
duced into  the  lungs  by  atomization,  in  as  large  quantity  as  possible. 

CARCINOMA   OF   THE    LUNG. 

Pathogeny. — Cancer  of  the  lung  is  usually  secondary,  and  very 
often  succeeds  to  cancer  of  the  breast  removed  by  amputation.  It 
may  be  primary,  but  rarely  so.  While  cancer  of  the  lung  as  a  second- 
ary disease  is  more  common  in  women,  primary  cancer  of  the  lung  is 
more  common  in  men.  It  is  a  disease  of  advanced  life,  and  is  extreme- 
ly rare  before  forty  ;  nevertheless,  a  case  has  occurred  at  twenty-five. 
The  form  of  cancer  which  attacks  the  lungs  is  usually  the  soft  and 
rapidly  growing  variety  known  as  encephaloid,  and  it  occurs  in  two 
forms — in  a  distinct  body  or  mass,  and  diffused  through  the  tissue  of 
the  lung.  In  either  case  it  presents  the  appearance  of  a  yellowish- 
white,  homogeneous,  rather  firm  material,  looking  like  brain-tissue 
which  had  been  somewhat  hardened — hence  the  name.  When  a  mass 
is  divided,  a  quantity  of  whitish,  albuminous-looking  fluid  may  be 
pressed  out,  and  this  fluid  is  called  cancer-juice.  Sometimes  this  can- 
cer-juice may  be  found  in  cyst-like  nodules,  or  in  delicate  canals,  whit- 
ish in  appearance,  accompanying  the  lymph-canals.  Cancer  may  occur 
in  any  part  of  the  lung  ;  when  primary,  in  about  two  thirds  of  the 
cases  in  one  lung,  and  when  secondary  in  both,  usually.  The  right 
lung  is  more  frequently  the  seat  of  cancer,  in  so  large  a  proportion  as 
two  to  one.  The  distribution  of  cancer  varies.  In  the  primary  form 
it  occurs  in  nodules,  from  a  pea  to  an  orange  in  size,  or  there  may  be 
a  great  number  of  the  smallest  nodules,  or  a  diffused  infiltration  involv- 
ing a  part  or  the  whole  of  a  lobe,  even  of  two  lobes.  When  it  forms 
a  distinct  tumor  of  considerable  size,  the  neighboring  parts  may  be 
compressed  :  the  lung  may  atrophy  from  pressure  ;  the  bronchi  may 
be  encroached  on  and  closed,  or  the  cancer  elements  may  enter  and  fill 
them  ;  blood-vessels  may  be  impinged  on,  their  lumen  obliterated,  or 
they  may  ulcerate  and  haemorrhage  result.  The  bronchi,  trachea,  and 
great  vessels  may  be  so  far  obstructed  as  to  interfere  with  their  func- 
tions respectively.  The  bronchial,  tracheal,  cervical,  and,  axillary 
glands  may  "be  enlarged  from  simple  adenitis,  or  from  cancerous  infil- 
tration.    The  pleura  is  usually  invaded  ;  there  may  be  an  effusion  into 


CARCINOMA  OF   THE   LUNG.  399 

the  cavity,  or  adhesions  unite  the  two  surfaces,  and  the  cancer  elements 
may  make  their  way  to  the  surface  as  nodules,  or  in  thin  plates.  A 
large  cancerous  mass  may  displace  organs,  push  the  heart  aside,  and 
force  the  liver  and  spleen  downward. 

Symptoms. — When  the  cancer  forms  a  tumor,  the  symptoms  pro- 
duced by  it  are  dullness  over  the  place  occupied,  increase  of  the  vo- 
cal fremitus,  and  bronchial  voice  and  breath  sounds  over  the  dull  area. 
These  sounds  may  have  the  cavernous  character  if  the  cancer-mass 
surrounds,  without  compressing,  a  large  bronchus.  Also,  a  large  artery, 
impinged  on  by  the  tumor,  will  give  forth  a  distinct  systolic  bruit, 
which  may  be  mistaken  for  aneurismal  hriiit,  unless  it  is  recognized 
that  there  is  but  one  center  of  pulsation  (the  heart)  in  the  chest.  If 
the  growth  be  so  situated  as  to  press  on  a  lai-ge  vein,  there  will  be  pres- 
ent oedema  of  the  head  and  face,  or  of  one  side;  if  it  press  on  the  recur- 
rent laryngeal,  spasm  of  the  glottis,  a  peculiar  cough  (croupy),  and  dif- 
ficult breathing,  or,  if  the  pressure  be  long  continued,  paralysis  with 
its  usual  consequences,  will  result ;  if  other  nerve-trunks  are  impinged 
on,  there  will  be  deep-seated  pains  in  the  thorax,  often  of  an  excru- 
ciating kind,  and  there  may  be  paroxysms  simulating  angina  pectoris. 
The  symptoms  become  more  complex  and  difficult  of  interpretation,  in 
cases  of  diffused  or  disseminated  cancer.  There  are  present  the  signs 
of  consolidated  lung-tissue  on  one  or  both  sides.  There  are  no  adven- 
titious sounds,  but  the  respiration  has  a  rather  blowing  character  in 
some  situations;  in  others,  that  of  bronchial  voice  and  bronchial  breath. 
The  diagnosis  rests  on  these  facts  :  all  acute  diseases  are  excluded,  as 
this  is  comparatively  slow  in  development  and  is  free  from  fever ;  it 
can  not  be  chronic  pneumonia,  as  there  is  no  localization  of  the  deposits; 
from  tuberculosis  it  is  separated  by  the  absence  of  fine  crackling,  and 
by  the  fever-movement ;  and,  lastly,  some  indurated  glands  may  be 
found  in  the  neck  or  axilla,  and  possibly  the  traces  of  a  former  opera- 
tion. There  will  be  some  difficulty  of  breathing  if  the  deposits  are 
extensive,  and  a  dry,  hard  cough  ;  but  there  may  occur,  finally,  rusty- 
colored,  semi-transparent,  gelatinous  expectoration.  The  difficulty  of 
breathing  depends  on  different  conditions  from  those  which  obtain  in 
the  other  form.  In  this  case,  the  degree  in  which  the  air-space  is  en- 
croached upon  determines  the  amount  of  dyspnoea  ;  in  the  other,  com- 
pression of  bronchi,  or  trachea,  or  displacement  of  the  lung,  affects  the 
breathing.  The  character  of  the  cough  is  very  different,  according  as 
it  is  due  to  deposits  in  the  lungs,  to  pressure  on  a  bronchus,  to  irrita- 
tion of  the  recurrent  laryngeal,  or  pneumogastric  nerves,  etc.  Besides 
the  symptoms  produced  by  and  due  to  the  presence  of  the  cancer  in 
the  lungs,  there  is  soon  developed  the  cancerous  cachexia,  which  is 
manifested  by  the  following  symptoms  :  progressive  emaciation,  weak- 
ness and  sense  of  fatigue,  a  weak,  small  pulse,  a  peculiar  earthy  or 
fawn-color  tint  of  the  skin,  pearly  sclerotic,  anorexia,  oedema  of  the 


400  DISEASES   OF   THE   RESPIRATORY   ORGANS. 

ankles,  etc.  The  rate  of  decline  due  to  the  cancer  deposits  is  acceler- 
ated by  the  harassing  cough,  the  dyspnoea,  the  dysphagia,  and  the 
pain.  As  the  cancer  extends,  all  of  the  rational  symptoms  increase  in 
severity,  and  the  physical  signs  more  clearly  indicate  the  diffusion  of 
the  cancer  elements  through  the  lungs,  or  the  enlargement  of  the  tumor. 
Treatment. — This  must  be  directed  by  the  symptomatic  indications. 
Anodynes  to  relieve  pain  and  support  for  the  increasing  weakness  are 
the  measures  necessary. 


HYDATIDS   OP   THE   LUNGS— ECHINOCOOCI. 

Definition. — Hydatids  found  in  the  lungs  are  the  intermediate  or 
larval  condition  of  the  taenia  echinococcus — the  tape-worm  of  the 
dog — and  are  therefore  designated  echinococci.  The  cysticercus  cellu- 
losus,  the  larval  state  of  the  tmnia  soliuin,  is  very  rarely,  if  ever,  found 
in  the  lungs.  Echinococci  migrate  from  the  intestines  and  take  up 
their  abode  in  the  lungs.  Each  cyst  contains  the  embryo — the  scolex 
with  its  four  suckers,  and  row  of  booklets,  inverted  and  contained 
within  its  cyst. 

Dermoid  cysts  are  rarely  found  in  the  thorax,  but  they  should  not 
be  confounded  with  echinococci. 

Pathological  Anatomy. — Hydatid  cysts  usually  exist  in  the  paren- 
chyma of  the  lungs,  but  sometimes  develop  in  the  cavity  of  the  pleura, 
or  they  may  be  present  in  both  at  the  same  time.  They  are  found  in 
the  inferior  lobe,  and  chiefly  on  the  right  side.  Often,  the  intra-tho- 
racic  cyst  is  a  solitary  hydatid,  which  fills  the  cavity,  distending  and 
enlarging  the  chest  on  that  side,  pushing  out  and  widening  the  inter- 
costal spaces,  compressing  the  lung  against  the  root  and  the  spinal  col- 
umn, and  forcing  the  heart  downward  or  to  one  side,  and  depressing 
the  liver  or  spleen.  If  the  cyst  is  large,  the  pleural  surfaces  may  be 
united  and  the  cavity  obliterated.  Adhesions  are  often  formed  to 
a  bronchus,  which  may  be  perforated  and  a  cure  effected  by  discharg- 
ing the  parasite  by  expectoration.  The  cavity  which  remains  con- 
tracts and  cicatrizes.  In  other  cases  the  parasite  is  not  discharged, 
but  sets  up  an  inflammatory  induration  about  it,  which  excites  fever, 
cough,  and  expectoration,  that  ultimately  exhaust  the  patient  unless 
carried  off  by  some  intercurrent  affection.  Rarely  do  hydatids  come 
into  relation  with  the  vessels  of  the  thorax,  but  a  vessel  may  be  in- 
vaded, with  results  determined  by  its  size.  Habershon  *  reports  a  case 
of  a  youth  of  seventeen  in  whom  repeated  haemorrhages  occurred,  from 
an  opening  into  a  branch  of  the  pulmonary  vein,  produced  by  "  ulcera- 
tion at  the  seat  of  the  hydatid  cyst."  In  this  case  tubercular  disease 
followed  the  troubles  due  to  the  hydatids.     Sometimes  the  cysts  attain 

*  "  Guy's  Hospital  Reports,"  third  series,  vol.  xviii,  18'72-"73,  p.  3*73. 


HYDATIDS  OF  THE  LUNGS.  401 

sufficient  volume  to  cause  death  by  suffocation.  In  other  cases  death 
is  produced  by  atrophy  of  the  inferior  lobes  of  the  lungs.  In  a  larger 
number  of  cases,  pneumonia  and  gangrene  of  the  lung,  induced  by  the 
presence  and  pressure  of  the  hydatids,  are  the  cause  of  death.  The 
length  of  time  hydatids  continue  in  the  lungs  is  measured  by  years. 
The  ordinary  duration  is  two  to  four  years. 

Symptoms. — The  cysts  must  attain  a  sufficient  size  to  interfere  with 
function  before  symptoms  are  produced.  More  frequently  than  in 
other  situations,  hydatids  of  the  lungs  give  rise  to  pains  which  may  be 
felt  in  the  back,  in  the  side,  or  in  the  epigastrium.  The  pain  is  severe, 
persistent,  and  is  somewhat  paroxysmal,  and  its  situation  may  indicate 
the  seat  of  the  mischief.  The  decubitus  is  on  the  back  or  on  the  af- 
fected side.  The  most  marked  as  well  as  the  most  constant  symptom 
is  dyspnoea,  which  is  always  present  in  a  moderate  degree  unless  the 
cyst  is  very  voluminous,  and  there  occur  also  violent  paroxysms,  in 
which  the  breathing  is  suffocative.  The  cough  is  dry,  or  accom- 
panied with  a  little  expectoration,  unless  the  cyst  communicate  with  a 
bronchus,  when  the  cough  is  incessant  and  the  expectoration  enormous, 
consisting  of  a  serous  liquid  or  earthy  and  calcareous  masses,  filled 
with  the  debris  of  hydatids.  Sometimes  the  expectoration  is  fetid,  from 
gangrene,  or  bloody.  Small  hydatids  of  the  volume  of  a  pigeon's-egg 
may  be  expected,  but  usually  fragments  and  booklets.  The  expectora- 
tion takes  place  at  intervals  sometimes  of  weeks  or  months  ;  then  a 
great  mass  may  come  up,  almost  suffocating  the  patient. 

The  physical  signs  will  depend  largely  on  the  volume  attained  by 
the  cysts,  their  number  and  situation.  There  may  be  seen,  on  inspec- 
tion, an  enlargement  of  the  affected  side,  dilatation  of  the  intercostal 
spaces,  and  displacement  of  the  heart  or  of  the  liver,  or  of  both.  Fluc- 
tuation or  the  purring  tremor  will  be  felt  only  if  the  cysts  are  protruding 
through  the  chest-walls,  and  if  a  number  of  daughter-vesicles  are  con- 
tained within  the  parent-cyst.  On  percussion,  there  will  be  dullness 
according  to  the  space  occupied,  and  increase  of  resistance,  commencing 
below  the  clavicle,  over  the  inferior  lobe.  The  vocal  fremitus  is 
diminished.  The  vesicular  murmur  is  absent,  replaced  by  bronchial 
voice  and  bronchial  breath.  Egophony  may  be  audible.  The  signs 
of  a  cavity  will  be  present  when  the  cysts  are  expectorated. 

Course,  Duration,  and  Termination. — The  origin  and  early  develop- 
ment of  echinococci  of  the  lung  necessarily  escape  detection.  It  is  only 
when  they  are  large  enough  to  interfere  with  neighboring  parts  that 
symptoms  are  produced.  The  whole  course  is  usually  completed  within 
four  years,  sometimes  earlier,  if  the  opportunity  for  free  discharge  ex- 
ists by  an  opening  into  a  bronchus.  In  forty  cases  of  which  Davaine  * 
has  given  an  account,  there  were  fifteen  recoveries  and  twenty-five 

*  "  Traite  des  Entozoaires,"  op.  cit.,  whose  account  I  have  closely  followed  in  this 
subject. 

26 


-1-02  DISEASES   or   THE   RESPIRATORY   ORGANS. 

deaths,  the  termination  by  expectoration  of  the  hydatids  occurring  in 
twelve  cases.  Of  the  twenty-five  fatal  cases,  twelve  or  thirteen  occu- 
pied the  inferior  lobe,  and  five  or  six  the  upper  lobe.  In  another  col- 
lection of  cases  quoted  by  Davaine,  of  sixty-two  terminating,  in  recov- 
ery forty-five  recovered  by  the  expectoration  of  the  cysts,  and  seven 
by  puncture  of  the  chest,  expectoration  also  occurring.  The  propor- 
tion of  cures  to  cases  in  the  last-mentioned-  collection  was  sixty-two  to 
eighty-two.  The  termination  by  death  is  therefore  more  common  than 
recovery.  Death  is  due  to  a  variety  of  causes — to  exhaustion  from 
profuse  purulent  expectoration,  hectic  and  marasmus,  to  tuberculosis, 
to  hasmorrhage,  to  gangrene,  to  pleuritis,  etc. 

Diagnosis. — There  are  no  well-marked  distinctions  between  hydatid 
cysts  and  pleuritic  effusion,  as  regards  the  physical  signs,  but  they  dif- 
fer widely  in  history.  Pleuritis  begins  by  a  violent  pain  in  the  side, 
chill  and  fever,  the  effusion  following  in  a  short  time.  Echinococci 
very  slowly  develop,  and  the  symptoms  of  effusion  are  not  produced 
until  after  many  months.  Puncture  and  examination  of  the  fluid  for 
the  characteristic  booklets  may  be  required,  to  determine  the  question 
at  issue.  When  expectoration  of  echinococci  or  of  fragments  takes 
place,  there  can  be  no  doubt  left. 

Treatment. — When  the  existence  of  hydatid  cysts  is  ascertained, 
there  should,  if  possible,  be  made  a  free  opening  to  permit  their  evacu- 
ation. Puncture  and  withdrawal  of  fluid  will  arrest  their  growth, 
but,  as  decomposition,  suppuration,  even  gangrene  may  result,  the  ex- 
trusion of  the  cysts  should  be  procured,  if  possible. 


CATARRH  OF  THE  BRONCHIAL  TUBES— ACUTE  BRONCHITIS- 
CAPILLARY  BRONCHITIS. 

Definition. — The  term  bronchitis  is  limited  to  a  catarrhal  inflamma- 
tion involving  the  bronchial  tubes,  of  a  caliber  above  the  terminal  tubes. 
Catarrhal  inflammation  of  these  terminal  tubes,  or  bronchioles,  is  desig- 
nated capillary  bronchitis,  and  if  associated  with  atelectasis  is  then 
known  as  catarrhal  pneumonia  or  broncho-pneumonia.  If  the  trachea 
is  at  the  same  time  affected  with  the  bronchial  tubes,  the  disease  is 
named  tracheo-bronchitis.  If  the  inflammation  is  general  over  the 
whole  tube,  it  is  called  diffuse  bronchitis  ;  if  limited  to  a  part,  circum- 
scribed bronchitis.  According  to  the  rate  of  progress,  it  is  acute  or 
chronic,  but  the  difference  is  slight. 

Causes.— Bronchitis  is  very  dependent  on  climatic  conditions.  A 
humid,  changeable,  and  cold  climate  favors  it,  while  dryness,  uniform- 
ity, and  warmth  of  climate  have  the  opposite  effect.  More  than  any 
other  single  factor  does  humidity  influence  and  promote  the  occurrence 
of  bronchitis.  Those  seasons  of  the  year  characterized  by  the  most 
rapid  alternations  of  temperature,  by  cold  and  damp  winds,  and  by  ex- 


ACUTE   BRONCHITIS.  403 

cess  of  humidity,  are  especially  liable  to  produce  bronchitis.  All 
depressing  hygienic  influences,  unsuitable  clothing,  exposure  to  damp, 
cold  air — especially  when  the  body  is  warm  and  perspiring — are  influ- 
ential factors.  In  a  lowered  state  of  the  general  health  from  any  cause, 
the  bronchial  mucous  membrane  is  more  susceptible  to  evil  influences. 
Bronchitis  occurs  in  greater  ratio  in  men,  because  they  are  more  ex- 
posed to  the  conditions  producing  it.  Age  has  an  unquestionable  in- 
fluence. The  extremes  of  life  are  more  susceptible,  but  in  infancy 
bronchitis  is  more  frequent  than  in  old  age,  but  from  different  causes. 
The  inhalation  of  irritating  gases  and  vapors  and  the  dust  of  various 
occupations  will  excite  inflammation  and  catarrh.  Among  the  causes 
must  be  placed  minute  organisms,  the  pollen  of  plants,  which  excite 
local  irritation  of  the  respiratory  tract,  and  epidemics  of  catarrhal  dis- 
eases. Valvular  affections  of  the  heart,  which  maintain  congestion  of 
the  lungs  and  bronchi,  necessarily  induce  a  catarrhal  state  of  the  bron- 
chial mucous  membrane. 

Pathological  Anatomy. — The  initial  factor  in  inflammation  of  the 
bronchial  mucous  membrane  is  hyperaemia,  or  increased  blood-supply, 
the  whole  surface  marked  by  a  fine  arborescent  or  punctif orm  redness, 
or  spots  or  limited  areas  only  are  thus  affected.  The  depth  of  color 
depends  on  the  period  and  intensity  of  the  disease — recent  and  severe 
inflammation  causing  deep  redness,  and  passive  inflammation  a  dark- 
red,  even  purplish  injection.  It  is  hardly  ever  the  case  that  the  entire 
bronchial  tract  is  invaded  by  the  redness,  but  portions  of  the  trachea, 
a  considerable  part  of  the  primary  and  some  portions  of  the  second  and 
third  divisions  of  the  bronchi.  In  old  cases  the  redness  disappears  and 
is  replaced  by  a  grayish,  ashy  hue,  with  relatively  numerous  enlarged 
and  tortuous  vessels  showing  through.  Nutritive  changes  in  the  epi- 
thelium, overgrowth  of  the  glands,  and  proliferation  of  the  connective- 
tissue  cells  of  the  submucosa,  increase  the  thickness  of  the  mucous 
membrane.  The  cartilaginous  rings  also  undergo  important  changes, 
and  the  peribronchial  connective  tissue  is  the  seat  of  an  active  hyper- 
plasia. The  new  connective-tissue  elements  displace  the  cartilage. 
The  secretion  of  the  mucous  membrane  is  changed  in  character  ;  at 
first  the  sudden  hypersemia  suspends  the  production  of  mucus  and  the 
membrane  is  dry  ;  the  next  step  consists  in  an  increased  production 
of  mucus,  soon  followed  by  purulent  elements,  which  rapidly  prepon- 
derate, giving  the  expectoration  a  yellowish  color.  The  amount  of 
secretion  varies  in  different  cases  :  when  it  is  deficient,  the  case  is 
known  as  dry  catarrh ;  when  pus  is  copiously  discharged,  it  receives 
the  name  of  hronchorrhoea.  The  extension  of  bronchitis  to  the  alveoli 
of  the  lungs  and  the  collapse  of  lobules  constitute  catarrhal  pneumo- 
nia. Emphysema  may  also  result,  especially  the  vicarious  emphysema, 
and  when  the  atelectatic  condition  happens  to  many  lobules.  The 
bronchial  glands  frequently  participate  in  the  inflammation,  become 


404  DISEASES  OF  THE  RESPIRATORY  ORGANS. 

hypersemic,  swollen,  -and  filled  with  secretion,  or  the  gland  elements 
undergo  hyperplasia  and  ultimately  the  cheesy  transformation. 

Symptoms. — There  may  be  catarrh  of  the  upper  air-passages,  and 
at  the  same  time  there  is  experienced  a  raw  and  sore  sensation  under 
the  sternum,  and  a  dry,  harsh,  and  rather  ringing  cough,  which  awak- 
ens jjain,  and  has  often  a  suppressed  character  because  of  the  pain. 
At  first  the  cough  is  dry,  corresponding  to  the  dry  stage  of  the  mucous 
inflammation,  and  is  most  troublesome  in  the  evening.  There  are  also 
m.uch  muscular  soreness  and  a  sense  of  fatigue,  but  no  other  symptoms 
of  illness.  In  other  cases  there  may  be  some  feyerishness,  headache, 
and  anorexia.  The  cough,  which  was  dry,  now  brings  up  some  mu- 
cus, at  first  only  after  repeated  coughing,  but  in  a  short  time  easily 
and  abundantly,  and  the  expectoration  at  last  has  an  entirely  purulent 
character,  and  comes  up  in  globular  masses.  The  fever  now  disap- 
pears, the  pain  and  soreness  cease,  the  cough  is  easy  and  less  frequent, 
the  appetite  is  restored,  and  the  return  to  health  is  completed  in  a  few 
days.  Such  is  the  course  of  a  simple  acute  bronchitis  (a  cold  on  the 
chest),  which  terminates  in  recovery  in  about  sixteen  days.  In  such  a 
case  the  changes  in  the  mucous  membrane,  we  may  suppose,  consist  in 
hypersemia  and  swelling,  with  increased  secretion  of  the  glands  and 
more  or  less  destruction  of  the  epithelium.  The  more  severe  cases  of 
bronchitis  come  on  with  muscular  soreness,  headache,  chilliness,  and 
fever.  There  is  not  a  single  violent  chill  marking  the  onset  of  the 
disease,  but  a  succession  of  chills  in  which  there  is  merely  some  chil- 
liness felt  several  times  during  the  course  of  the  day,  and  having  no 
influence  on  the  fever,  which  has  an  exacerbation  in  the  evening  and  a 
remission  in  the  morning,  or  a  complete  intermission.  Sometimes  the 
febrile  movement  exists  without  there  being  any  other  symptoms  for 
several  days,  but  the  more  usual  onset  is  the  simultaneous  appearance 
of  chest  symptoms.  There  is  a  sensation  of  heat  and  stufiing  under  the 
sternum  ;  cough,  which  is  accompanied  by  soreness  within  the  chest, 
now  comes  on,  and  it  is  dry,  harsh,  ringing.  The  frequency  and  force 
of  the  coughing  make  the  diaphragm  and  chest-muscles  sore,  and  now 
and  then  the  stomach  is  emptied  in  a  violent  paroxysm.  In  a  few  days 
— usually  from  three  to  five — the  dryness  of  the  mucous  membrane 
ceases,  and  abundant  secretion  of  mucus  now  takes  place,  and  there  is 
brought  up  frothy  mucus,  which  day  by  day  assumes  more  of  a  puru- 
lent character.  The  fever  now  declines  somewhat,  but  frequently  a 
gastro-intestinal  catarrh  is  lighted  up  and  diarrhoea  supervenes.  This 
is  apt  to  be  the  case  with  children,  in  whom  the  nausea,  vomiting,  and 
diarrhoea  assume  an  important  position.  The  coincident  development 
of  bronchial  and  gastro-intestinal  catarrh  produces  a  complexus  of 
symptoms  to  which  the  term  catarrhal  fever  has  been  applied.  In 
bronchitis  the  sonority  of  the  chest  is  not  altered  from  the  normal. 
During  the  dry  stage  the  swelling  of  the  mucous  membrane  narrows 


ACUTE  BRONCHITIS.  405 

somewhat  the  lumen  of  the  bronchial  tubes,  but  there  is  no  secretion 
to  produce  a  new  sound.  The  passage  of  air  through  narrowed  tubes 
modifies  the  vibrations,  and  hence  the  terms  sibilant  and  sonorous 
rdles,  audible  at  this  stage,  both  with  Inspiration  and  expiration. 
When  secretion  of  mucus,  muco-pus,  and  pus  succeeds  to  the  dryness, 
the  rdles  are  said  to  be  moist.  Those  are  suh-crepitant  w^hich  are  produced 
in  the  smaller  tubes,  and  mucous  and  sub-mucous  formed  in  the  larger 
tubes.  The  largest  sounds,  or  gurgling,  are  produced  only  in  ca\dties, 
or  that  which  is  equivalent,  dilated  bronchi.  The  sub-crepitant  is  more 
distinct  in  inspiration,  but  all  of  these  rdles  are  audible  both  in  inspi- 
ration and  expiration.  Moist  sounds  are  modified  by  coughing  and 
expectoration — may,  indeed,  be  caused  to  disappear  by  them. 

The  usual  termination  of  these  cases  of  bronchitis  is  in  resolution. 
The  fever  ceases,  the  tongue  cleans,  the  appetite  improves,  the  cough  sub- 
sides, the  expectoration  is  copious,  easy,  and  purulent,  but  the  amount 
declines  rapidly.  Certain  types  of  subjects  manifest  a  great  suscep- 
tibility to  attacks  of  bronchial  catarrh,  and  the  effects  do  not  cease. 
This  is  the  case  in  the  dyscrasire,  and  when  the  catarrh  is  due  to  car- 
diac disease  there  can  only  be  a  temporary  subsidence  in  the  severity 
of  the  symptoms.  In  those  debilitated  by  constitutional  causes,  or  in 
subjects  of  the  strumous  type,  the  acute  attack  passes  into  the  chronic 
form.  Acute  bronchitis,  by  an  extension  of  the  inflammation  to  the 
finest  tubes,  becomes  capillary  bronchitis.  This  is  often  the  case  in 
whooping-cough,  and  in  the  eruptive  fevers — notably  in  measles.  In 
those  debilitated  by  previous  illness,  in  the  old,  and  in  infants,  capil- 
lary bronchitis  is  a  most  serious  malady.  A  sudden  increase  in  the 
temperature  and  a  marked  difficulty  of  breathing  announce  the  onset 
of  this  disease  when  it  arises  as  just  indicated.  So  difficult  is  the 
breathing  that  the  patient  calls  into  use  the  auxiliary  muscles  of  respi- 
ration ;  unable  to  lie  down,  he  sits,  inclined  forward,  the  arms  resting 
on  some  support,  struggling  to  get  breath,  and  the  respirations,  shallow 
and  incomplete,  reaching  in  an  adult  to  forty,  in  infants  to  eighty  per 
minute.  The  difficulty  of  breathing  is  incessant ;  although,  now  and 
then  dislodging  some  mucus  by  coughing  or  vomiting,  there  is  a  tem- 
porary alleviation  of  the  distress.  At  first  the  respirations,  although 
hurried  and  oppressed,  are  normal ;  but,  when  the  air  can  not  enter,  the 
lungs  are  not  expanded,  and  the  diaphragm  is  not  depressed,  the  inferior 
part  of  the  chest  and  the  epigastrium  are  drawn  in  with  each  inspira- 
tion instead  of  being  elevated,  while  the  upper  portion  of  the  chest  re- 
mains immovable.  At  first  the  face  is  red,  the  eye  bright,  and  the 
skin  hot  with  the  unwonted  effort,  but  as  the  air  fails  to  reach  the 
lungs  the  blood  is  not  oxygenated,  the  face  becomes  pale,  the  veins 
enlarged,  and  the  countenance  has  an  increasing  duskiness  from  the 
accumulation  of  carbonic  acid  in  the  blood.  The  restlessness  and 
anxiety  yield  to  an  increasing  stupor,  and  the  approaching  cardiac 


406  DISEASES   OF   THE   RESPIRATORY   ORGANS. 

failure  is  announced  by  rapidity  and  feebleness  of  the  pulse.  When 
no  efforts  succeed  in  removing  the  obstruction  to  the  entrance  of  air, 
death  takes  place  in  four  or  five  days,  but  the  duration  is  longer  if  by 
vomiting  or  other  means  the  access  of  air  is  secured,  even  for  a  brief 
period,  to  the  alveoli  of  the  lungs.  When  a  favorable  termination  is 
about  to  take  place,  the  dyspnoea  becomes  less  urgent,  the  pulse  im- 
proves in  volume  and  lessens  in  rate,  the  fever  diminishes,  the  expec- 
toration is  less  viscid  and  comes  up  more  abundantly,  and  ten  or  twelve 
days  from  the  onset  convalescence  is  fairly  inaugurated.  More  or  less 
simple  bronchitis  may  persist  for  weeks  longer.  The  physical  signs  are 
similar  to  those  of  bronchitis,  except  the  differences  due  to  the  volume 
of  the  tubes  attacked.  Besides  the  coarser  sounds  of  bronchitis,  the 
dominating  rale  is  the  sub-crepitant,  audible  all  over  the  chest.  As  in 
capillary  bronchitis  collapse  of  lobules  takes  place,  the  physical  signs 
of  atelectasis  are  superadded.  These  have  already  been  sufficiently 
discussed. 

Course,  Duration,  and  Termination. — Simple  bronchitis  usually  ter- 
minates in  resolution  in  about  ten  to  fifteen  days.  In  children  the 
course  may  be  more  protracted,  and  the  symptoms  more  severe,  if 
complicated  by  gastro-intestinal  troubles.  The  termination  may  be  in 
the  chronic  form  of  the  disease.  There  may  be  an  extension  of  the 
morbid  action  from  the  larger  to  the  finest  bronchial  tubes.  Capillary 
bronchitis  pursues  a  more  rapid  course,  and  may  terminate  in  four  or 
five  days,  but  it  usually  continues  up  to  the  ninth,  even  twelfth  day. 
The  mortality  from  capillary  bronchitis  is  large,  because  of  the  occur- 
rence of  atelectasis  and  broncho-pneumonia  or  catarrhal  pneumonia. 

Diagnosis. — Acute  bronchitis  is  to  be  differentiated  from  catarrhal 
pneumonia  and  croupous  pneumonia.  Bronchitis  pursues  a  much  milder 
course,  is  of  shorter  duration,  and  is  greatly  less  dangerous  to  life. 
While  the  moist  sounds  are  the  same  in  the  two  diseases,  the  sub-crepi- 
tant rale  preponderates  in  catarrhal  pneumonia,  and  in  the  latter  the 
vesicular  murmur  is  replaced  by  blowing  or  bronchial  breathing  and 
bronchial  voice.  Bronchitis  commences  by  chilliness  persisting  for 
several  days — pneumonia  by  a  distinct  and  severe  rigor  ;  in  bronchitis 
there  is  fever  of  moderate  height — in  pneumonia,  the  range  of  temper- 
ature is  very  high  ;  in  bronchitis,  the  fever  declines  gradually — in 
pneumonia,  there  is  a  sudden  defervescence  ;  in  bronchitis,  the  sputa 
consist  of  muco-pus  and  pus — in  pneumonia,  of  a  peculiar  viscid  mate- 
rial stained  with  blood  ;  in  bronchitis,  there  are  moist  sounds,  with  sub- 
crepitant  rale — in  pneumonia,  there  is  crepitant  rale  ;  in  bronchitis, 
there  are  no  sounds  indicating  pulmonary  lesions — in  pneumonia,  there 
are  bronchial  breathing,  bronchial  voice,  etc.  Bronchitis  of  the  larger 
is  to  be  distinguished  from  bronchitis  of  the  smaller  tubes,  by  the 
dyspnoea,  by  the  fineness  of  the  sounds,  and  the  greater  danger  to  life. 
The  onset  of  catarrhal  pneumonia  from  bronchitis  is  announced  by 


CHRONIC  BROXCHITIS.  407 

the  increased  difficulty  of  breathing,  the  rise  of  temperature,  and  the 
diminishing  sonority  of  the  chest  over  the  affected  parts,  with  the 
auscultatory  phenomena  of  consolidation. 

Treatment. — The  simplest  means  suffice  for  an  uncomplicated  case 
of  acute  bronchial  catarrh.  The  combination  of  tartar  emetic  (gr.  -^) 
and  morphia  (gr.  Jj)  in  some  sii-up  of  lactucarium,  or  in  water,  a 
mustard-plaster  to  the  chest,  and  confinement  to  bed,  will  afford  satis- 
factory relief.  In  children,  sirup  of  ipecac,  sirup  of  tolu,  and  paregoric 
usually  suffice.  If  there  is  much  fever,  and  the  pulse  active,  tincture 
of  aconite-root  (gt.  j)  should  be  added  to  the  ipecac  and  paregoric. 
When  the  acute  symptoms  have  subsided,  the  stimulant  expectorants 
should  be  used — acetum  scillae,  sirup  of  senega,  and  sirup  of  tolu,  for 
example.  When  the  bronchitis  is  severe,  there  is  high  fever,  and  the 
inflammation  seems  disposed  to  invade  the  finer  tubes,  and  especially 
if  the  finer  tubes  are  invaded,  tartar  emetic  in  sufficient  quantity  to 
produce  a  little  nausea,  morphia  in  very  small  doses,  and  the  tincture 
of  aconite,  are  highly  serviceable.  The  more  the  finer  tubes  are  in- 
vaded, the  greater  the  need  of  ammonia,  carbonate  or  chloride,  and  the 
iodide.  Should  there  be  much  obstruction,  emetics  of  subsulphate  of 
mercury  or  of  apomorphia  must  be  employed  to  tide  over  the  emer- 
gency, and  then  the  iodide  and  carbonate  of  ammonia,  in  small  doses, 
should  be  given  frequently.  Should  the  temperature  rise  high  and 
continue  so,  antipyretics,  as  cold  baths  and  quinia,  more  especially  the 
latter,  must  be  administered.  A  temjaerature  requiring  antipyretics 
may  be  attained  when  a  simple  bronchitis  becomes  a  capillary  bron- 
chitis or  broncho-pneumonia.  A  persistently  high  temperature  greatly 
increases  the  danger  of  cardiac  failure.  If  there  be  indications  of  such 
failure,  ammonia  carbonate  and  alcoholic  stimulants  must  be  freely 
but  judiciously  administered.  The  diminution  in  the  supply  of  oxygen 
and  the  accumulation  of  carbonic  acid  are  important  sources  of  danger 
in  capillary  bronchitis.  The  timely  use  of  emetics,  by  giving  at  least 
temporary  admission  of  air,  will  postpone  the  period  of  stupor  from 
carbonic-acid  narcosis.  When  bronchitis  in  children  assumes  the  aspect 
of  catarrhal  fever,  the  remedies  employed  must  be  different  in  charac- 
ter. Nauseants,  emetics,  and  irritants  must  be  discontinued  if  they 
have  been  used.  Paregoric,  with  some  carbonate  of  ammonia,  in  sirup 
of  tolu,  is  a  good  prescription  in  these  cases.  In  all  cases  of  the  differ- 
ent forms  of  acute  catarrh  of  the  bronchial  tubes,  alimentation  is 
important,  but  especially  so  in  those  cases  accompanied  by  gastro- 
intestinal disorder. 


CHRONIC  BRONCHITIS— CHRONIC  BRONCHIAL  CATARRH. 

Definition. — By  this  term  is  meant  an  inflammation  beginning  in 
the  mucous  membrane  of  the  bronchial  tubes,  chronic  in  type,  and  in- 


408  DISEASES   OF   THE   RESPIRATORY   ORGANS. 

volving  not  only  the  mucous  membrane,  but  the  substance  of  the  tubes 
and  the  peribronchial  connective  tissue. 

Causes. — Chronic  bronchitis  but  rarely  succeeds  to  a  pronounced 
acute  attack.  Usually  the  early  symjDtoms  escape  recognition,  or  the 
chronic  form  is  a  resultant  of  not  one  but  numerous  acute  attacks. 
This  malady  is  always  associated  with  obstructive  lesions  of  the  heart 
or  lungs.  It  accompanies  or  is  a  local  development  of  the  dyscrasiae, 
as  rickets,  scrofula,  Bright's  disease,  and  of  the  infectious  diseases. 
The  tendency  to  it  may  be  inherited,  or  rather  a  type  of  mucous  mem- 
brane disposed  to  such  changes  may  be  transmitted. 

Pathological  Anatomy. — The  mucous  membrane  is  brownish  in  color, 
or  has  a  steel-gray  color.  In  other  examples,  owing  to  the  develop- 
ment of  vascular  loops,  it  has  a  bright-red  color.  The  follicles  of  the 
mucous  membrane  are  swollen  and  enlarged  by  hypertrophic  thicken- 
ing of  the  connective  tissue,  and  by  accumulation  of  their  contents. 
The  connective  tissue,  especially  of  the  posterior  part  of  the  tubes, 
and  the  peribronchial  connective  tissue,  become  greatly  thickened ;  the 
cartilages  are  invaded  and  much  weakened.  Under  the  strain  of  cough- 
ing, especially  if  there  be  at  the  same  time  firm  pleuritic  adhesions,  the 
bronchi  yield  and  dilate.  The  dilatations  are  cylindrical,  fusiform, 
and  sacculated.  In  cylindrical  dilatations  the  tube  or  tubes  are  uni- 
formly enlarged  throughout  ;  in  the  fusiform  variety  the  enlargement 
has  a  spindle-shape,  and  in  the  sacculated  there  is  a  lateral  protrusion 
forming  a  sac  or  a  cavity.  To  these  might  also  be  added  the  monili- 
form,  in  which  there  is  an  enlargement  of  one  part,  then  the  tube  is 
normal,  then  again  an  enlargement,  so  that  the  normal  portions  by  com- 
parison with  the  dilated  seem  to  be  contracted. 

The  secretions  in  chronic  bronchitis  differ  greatly  from  the  normal. 
Fragments  of  the  detached  epithelium,  mucus,  and  pus-corpuscles,  are 
the  morphotic  elements,  the  purulent  being  very  largely  in  excess. 
Usually  the  secretion  is  very  abundant,  greenish-yellow  in  color,  and 
sometimes  fetid.  When  the  secretion  consists  of  young  cells  and  mu- 
cus corpuscles  and  granules,  it  is  called  mucous  catarrh  ;  when  the  cel- 
lular elements  are  not  present,  and  the  secretion  is  viscid,  colorless, 
without  odor,  and  resembling  white  of  ^q^g,  it  is  called  pituitous  catarrh 
or  hronchorrhoea ;  if  the  secretion  is  scanty,  tough,  rather  glistening, 
semi-transparent,  and  occurs  in  defined,  globular  masses,  it  is  entitled 
dry  catarrh.  Whenever  the  secretion  is  retained  and  undergoes  decora- 
position,  as  is  apt  to  be  the  case  when  the  tubes  are  dilated,  especially 
in  the  saccular  form,  it  is  known  as  fetid  hronchitis,  the  fetor  being 
chiefly  due  to  the  fat  acids. 

Sjrmptoins. — If  there  be  no  complications,  chronic  bronchitis  is  not 
attended  by  fever.  When  it  occurs  with  disease  of  the  heart,  Bright's 
disease,  or  other  dyscrasiae,  the  clinical  features  are  those  of  the  origi- 
nal malady,  bronchitis  being  one  only  of  the  morbid  complexus.     As  a 


CHRONIC  BRONCHITIS.  409 

substantive  affection  succeeding  to  acute  attacks,  it  is  slow  of  develop- 
ment. There  are  observed,  for  some  years,  autumnal  and  winter  seiz- 
ures of  bronchitis,  which  cease  with  the  warmer  and  more  stable 
weather  of  the  summer.  It  may  be  a  number  of  years  before  the 
bronchitis  becomes  constant,  which  indicates  the  existence  of  perma- 
nent changes  in  the  tubes.  In  the  so-called  dry  catarrh  there  is  but 
little  expectoration,  and  that  is  brought  up  with  difficulty,  and  after 
repeated  and  most  distressing  paroxysms  of  coughing.  Next  to  cough- 
ing the  most  important  symptom  is  dyspnoea,  due  to  the  viscidity  of 
the  exudation,  to  the  swelling  of  the  mucous  membrane,  and  the  impli- 
cation of  the  finer  tubes.  The  difficulty  of  breathing  is  not  consider- 
able when  at  rest,  but  exertion  at  once  develops  it,  and  it  is  accom- 
panied by  more  or  less  wheezing.  Owing  to  the  impaired  elasticity  of 
the  lung  and  the  dilatation  of  the  tubes,  the  upper  part  of  the  thorax 
is  kept  in  the  position  of  maximum  inspiration,  and  the  expiration  is 
prolonged  and  difficult.  The  result  is,  that  the  supply  of  oxygen  is 
insufficient  for  the  depuration  of  the  blood,  and  cyanosis  appears,  the 
face  becomes  congested,  the  lips  and  mucous  membrane  bluish,  and  the 
supei-ficial  veins  enlarged.  The  pulmonary  circulation  is  hindered  by 
reason  of  these  conditions,  venous  stasis  ensues,  and  oedema  slowly 
develops  about  the  ankles.  The  habitual  difficulty  of  breathing  is  now 
and  then  varied  by  attacks  which  have  an  asthmatic  character,  excited 
by  the  inhalation  of  dust,  remaining  in  a  crowded  apartment,  taking 
cold,  and  especially  by  an  attack  of  acute  bronchitis  with  profuse 
secretion  (humid  asthma).  These  seizures  are  not  very  protracted,  and 
terminate  after  some  hours  by  an  abundant  discharge  of  mucus.  The 
cases  of  chronic  bronchitis  characterized  by  profuse  expectoration  dif- 
fer from  the  preceding  type  in  several  respects — in  a  more  abundant 
expectoration,  in  a  less  troublesome  cough,  and  in  less  habitual  difficulty 
of  breathing.  In  these  cases  of  so-called  humid  bronchitis  there  are 
occasional  paroxysms  of  dyspnoea,  due  to  extension  of  the  morbid 
process  to  the  smaller  tubes,  causing  difficulty  of  breathing  by  swell- 
ing of  the  mucous  membrane,  by  accumulation  of  secretion,  etc. 
With  or  without  such  paroxysms,  the  chief  troubles  arise  from  the 
cough,  which  is  most  annoying  at  night  or  in  the  early  morning,  and 
an  abundant  expectoration.  The  sputa  consist  of  muco-pus,  or  of  a 
semi-transparent,  albuminous,  viscid  fluid  (bronchorrhoea),  or  of  a  green- 
ish-yellow pus,  and  the  variations  represent  differences  in  the  local 
changes  already  designated.  Percussion  reveals  no  change  in  the  noi-- 
mal  sonority  of  the  lungs  in  uncomplicated  cases.  If  emphysema,  or 
broncho-pneumonia,  or  fibroid  phthisis  have  occurred,  there  will  be 
changes  in  sonority,  but  these  diseases  are  not  in  question.  In  dry 
bronchitis,  on  auscultation  sibilant  and  sonorous  rales  of  every  variety 
will  be  heard  ;  in  humid  bronchitis,  mucous  and  sub-mucous,  and  sub- 
crepitant  rales  will  be  abundant  according  to  the  amount  of  secretion 


410  DISEASES  OF  THE   RESPIRATORY   ORGANS. 

present  in  the  tubes.  The  vesicular  murmur  may  be  entirely  displaced 
by  the  loud  oodles,  especially  the  more  nearly  the  lesions  approach  to 
the  acini.  Dilatation  of  the  tubes  impresses  some  special  characters 
on  the  rational  and  physical  signs.  The  expectoration  is  very  abun- 
dant and  often  has  a  butyric  and  fetid  odor,  and  is  sometimes,  as  in  the 
morning,  expectorated  in  a  great  mass,  due  to  the  emptying  of  a  sac- 
culated dilatation  of  a  bronchus.  This  expectoration,  when  collected, 
differs  from  that  of  phthisis  in  being  homogeneous  and  of  a  greenish- 
yellow  color.  Haemorrhage  from  a  dilated  bronchus  is  a  very  mislead- 
ing symptom  ;  it  may  occur  gradually  and  continue  for  some  time,  there 
being  considerable  loss  in  the  aggregate.  The  blood  coming  from  a 
dilatation  is  fluid,  dark,  and  does  not  clot,  and  it  may  be  mixed  with 
the  contents  of  the  sac.  The  physical  signs  of  dilated  bronchi  are 
practically  the  same  as  those  of  a  cavity  formed  in  other  ways,  but 
the  distinction  may  be  made  by  the  history  of  the  case  and  by  the 
situation  of  the  dilatation. 

Course,  Duration,  and  Termination. — Chronic  bronchitis  pursues  an 
essentially  chronic  course,  but  it  is  diversified  by  variations  in  the 
intensity  of  the  symptoms,  by  remissions  and  intermissions.  These 
intermissions  are  only  possible  in  the  early  period  ;  after  a  time  the 
symptoms  persist.  Chronic  bronchitis  may  continue  during  a  lifetime, 
and  death  be  caused  by  some  other  disease.  Recovery  may  ensue  in 
the  milder  cases,  and  is  more  likely  to  occur  in  young  than  in  old  sub- 
jects. Severe  cases  of  bronchitis  lead  to  the  jDroduction  of  other  mal- 
adies. The  long-existing  purulent  exudation  in  the  tubes,  interstitial 
pneumonia  having  been  produced  by  the  extension  of  the  peribron- 
chial connective-tissue  inflammation,  excites  tubercular  deposition. 
Fibroid  phthisis  is  usually,  probably  always,  produced  in  this  way, 
chronic  bronchitis  initiating  the  series  of  morbid  changes.  Emphy- 
sema is  a  result  of  dry  catarrh,  for  in  this  case  the  chronic  inflamma- 
tion is  seated  in  the  finer  bronchi,  the  secretion  is  highly  viscid,  the 
membrane  much  swollen — conditions  most  favorable  to  collapse  of 
lobules  and  emphysema.  Hypertroi^hy  and  dilatation  of  the  right 
cavity,  venous  stasis,  and  general  (Edema  are  also  results  of  chronic 
bronchitis,  and  in  this  way  a  considerable  proportion  terminate.  The 
disturbed  circulation  in  the  lungs  and  the  venous  stasis  cause  conges- 
tion of  the  liver  and  of  the  kidneys,  and  death  may  be  due  to  the 
maladies  thus  created. 

Diagnosis. — The  same  considerations  govern  the  diagnosis  of  chron- 
ic as  of  acute  bronchitis.  The  disease  with  which  chronic  bronchi- 
tis is  most  apt  to  be  confounded  is  phthisis.  The  difficulty  of  sepa- 
rating chronic  bronchitis  with  sacciform  dilatation  from  phthisis 
with  cavities  is  very  great.  The  differentiation  must  rest  on  the 
history  of  the  cases,  the  evidence  of  pulmonary  lesions  outside  of 
the  cavity,  to  be  discovered   in   jDhthisis   and  not  in  bronchitis,  and 


CHRONIC  BRONCHITIS.  411 

in  examination  of  the  sputa,  those  of  phthisis  containing  elastic  fibrous 
tissue,  etc. 

Treatment. — The  indications  of  treatment  vary  somewhat  with  the 
form.  In  dry  bronchitis,  full  doses  of  iodide  of  potassium,  or  prefer- 
ably iodide  of  ammonium  (ten  to  twenty  grains),  every  three  hours 
when  the  difficulty  of  breathing  is  great,  are  very  effective.  For  the 
interval  between  the  asthmatic  paroxysms,  the  best  results  are  obtained 
by  a  combination  of  iodide  of  ammonia  and  arsenic,  with  a  balsamic 
expectorant,  as  eucalyptol,  turpentine,  copaiba,  cubebs,  etc.  The  per- 
sistent use  of  these  remedies  will  often  accomplish  important  results, 
and  will  in  all  cases  afford  relief,  if  not  cure.  When  there  is  profuse 
expectoration,  quinia  with  atropia,  and  codeia,  to  quiet  cough,  and  the 
balsams,  are  the  most  efficient  remedies.  If  the  expectoration  is  fetid, 
the  free  internal  use  of  quinia,  eucalyptol,  and  turpentine,  is  to  be  com- 
mended, and  inhalations  of  the  vapor  of  turpentine  and  of  iodine,  or 
atomization  of  benzoate  of  sodium,  carbolic  or  salicylic  acid,  or  thymol, 
may  be  practiced.  Of  these  remedies  applied  by  atomization,  carbolic 
acid  is  most  efficient.  In  all  cases  of  chronic  bronchitis  with  consider- 
able expectoration,  much  good  results  from  the  persistent  use  of  the 
now  well-known  phosphate  of  ii'on,  quinia,  and  strychnia.  The  lacto- 
phosphate  of  lime  is  also  highly  useful,  probably  because  of  the  waste 
of  this  important  material  under  these  circumstances  of  profuse  sup- 
puration. Arsenic  is  highly  useful  when  the  secretion  is  not  abundant, 
as  in  dry  bronchitis.  It  may  be  combined  with  the  iodides,  or  with 
the  sirup  of  the  lactophosphate  of  lime.  The  hypophosphites,  as  well 
as  the  compound  phosphates,  are  useful  when  there  is  waste  by  sup- 
puration. Alcohol  has  the  power  to  diminish  suppuration  and  to  arrest 
fermentative  processes,  and  is  therefore  useful  in  chronic  bronchitis. 
Whisky  is  the  best  alcoholic  in  such  cases.  It  may  be  taken  with  cod- 
liver  oil,  the  two  forming  a  nutrient  of  much  value — a  teaspoonful  of 
cod-liver  oil  and  a  tablespoonful  of  whisky  after  meals.  A  generous 
supply  of  nutritrous  aliment  is,  of  course,  highly  necessary. 

As  taking  cold  is  the  principal  cause  of  attacks  of  catarrh  (employ- 
ing that  terra  to  indicate  the  nature  of  the  influences  causing  catarrh), 
it  is  highly  important  to  avoid  this  accident  by  suitable  clothing,  by 
good  air,  and  by  favorable  hygienic  surroundings.  If  a  cold  should 
occur,  the  patient  ought  to  receive  at  once  an  efficient  dose  of  quinia  and 
morphia  (gr.  xv — gr.  ss.).  As  a  humid,  variable  climate,  characterized 
by  cold  winds  and  extremes  of  temperature,  is  very  unfavorable,  a 
change  to  a  mild,  equable,  and  dry  climate  should  be  advised. 

PSEUDO-MEMBRANOUS  OR   CROUPOUS   BRONCHITIS. 

Definition. —  Croupous  bronchitis  is  an  inflammation  of  the  bron- 
chial mucous  membrane,  characterized  by  the  exudation  of  a  false 


412  DISEASES  OF  THE  RESPIRATORY  ORGANS. 

membrane.  It  corresponds  to  croupous  enteritis  and  to  laryngeal 
croup.     It  may  be  acute  or  chronic. 

Causes. — The  ordinary  causes  of  bronchitis  excite  this  form  appar- 
ently, but  nothing  is  known  of  the  conditions  which  give  this  direc- 
tion to  the  products  of  inflammation.  The  cases  occur  usually  in 
youthful  subjects,  from  six  to  forty  *  years  of  age,  and  in  those  who 
have  been  subject  to  attacks  of  bronchial  catarrh.  A  depressed  state 
of  the  body,  and  possibly  an  inherited  tendency,  are  also  causes.  Ac- 
cording to  Riegel,  pulmonary  haemorrhage  sometimes  precedes,  accord- 
ing to  Street  succeeds  to  attacks  of  croupous  bronchitis. 

Morbid  Anatomy. — There  are  two  forms  of  the  croupous  process  in 
the  bronchial  tubes — the  diffused  and  the  circumscribed :  the  former 
are  so  designated  because  the  exudation  extends  from  the  trachea 
through  all  the  divisions  of  the  bronchi ;  the  latter,  because  confined 
to  certain  tubes.  The  mucous  membrane  has  been  found  both  intensely 
injected  and  pale  ;  the  epithelium  intact,  or  entirely  removed  over  the 
whole  extent  of  the  surface  covered  by  the  exudation.  Sometimes  cili- 
ated and  cylindrical  epithelium  has  been  found  embraced  in  the  casts  ; 
in  other  cases  none  has  been  found.  These  contradictory  observa- 
tions are  due  to  the  fact  that  the  examinations  were  made  at  differ- 
ent stages  of  the  disease.  Indeed,  displacement  of  the  epithelium  is 
not  a  necessary  part  of  the  process  of  membrane  formation.  It  is 
most  probable  that  an  albuminous  solution  is  poured  out,  and  white 
corpuscles  migrate,  the  whole  consolidating.  It  may  happen  that  some 
epithelial  cells  are  embraced,  but  this  is  not  necessary.  The  tubular 
casts  form  an  outline  of  the  tubes  in  which  they  were  produced.  They 
may  be  rolled  up  into  a  ball,  or  expelled  in  fragments,  or  as  a  whole. 
The  author  has  had  a  case  in  which  a  complete  cast  of  one  bronchus 
and  all  of  its  subdivisions  was  expelled  entire.  The  casts  differ  much 
in  thickness  and  length.  Those  coming  from  the  upper  tubes  are 
shorter  and  straighter,  and  terminate  in  fine  prolongations  ;  those  from 
the  lower  tubes  are  longer,  and  gradually  divide  into  smaller  casts. 
They  are  not  solid  usually,  at  least  the  larger  casts  are  not,  and  contain 
in  their  interior  mucus  and  air.  They  have  a  lamellated  structure, 
and  the  lamellae  have  a  concentric  arrangement  (Riegel)  f.  The  casts 
are  elastic  and  compact,  and  bear  a  good  deal  of  strain.  They  are 
whitish  or  yellowish-white  in  color,  and  consist  of  a  "hyaline  base- 
ment substance,"  J  sometimes  fibrillated,  as  was  the  case  in  the  author's 
observation. 

Symptoms. — There  are  two  forms — as  regards  the  clinical  features 
— the  acute  and  chronic.    The  acute  attacks  begin  as  an  ordinary  acute 

*  Dr.  Street's  case — a  man  aged  thirty -nine,  "  American  Journal  of  Medical  Sciences," 
January,  1880,  p.  149. 

f  Ziemssen's  "  Cyclopaedia,"  vol.  iv. 

\  "Report  of  Cases  of  Fibrinous  Bronchitis,"  by  Dr.  Glasgow. 


CROUPOUS  BRONCHITIS.  413 

bronchitis,  with  chilliness,  fever,  general  malaise,  a  troublesome  cough, 
soreness  of  the  chest,  and  oppression.  These  symptoms  continue  for 
several  days,  when  more  formidable  troubles  are  manifested  by  an  in- 
creasing dyspnoea,  "  livid,  swollen  countenance,"  *  high  fever,  rapid 
pulse,  a  dry,  harsh,  and  resonant  cough,  anxiety,  and  sometimes  haemop- 
tysis. There  may  be  no  preliminary  symptoms  of  acute  bronchitis 
merely,  but  the  disease  set  in  at  once  by  severe  difficulty  of  breathing, 
preceded  by  a  rigor,  and  accompanied  by  high  fever.  At  first  the  ex- 
pectoration is  that  of  bronchitis,  but  in  a  few  days  the  characteristic 
casts  are  brought  up  with  a  good  deal  of  coughing  and  straining.  There 
may  be  then  immediate  relief  afforded,  the  dyspnoea  subsiding  and  the 
cough  becoming  much  less  severe.  In  the  course  of  a  few  hours,  or  a 
day  or  two,  there  may  be  a  recurrence  of  the  severe  dyspnoea  and  the 
straining  cough,  and  more  casts  will  then  be  discharged.  More  or  less 
haemorrhage  may  occur,  or  masses  of  bloody  mucus  may  be  expecto- 
rated. In  the  chronic  form  of  croupous  bronchitis,  there  is  usually  a 
history  of  chronic  bronchial  catarrh,  or  of  some  form  of  pulmonary  dis- 
ease. During  the  course  of  such  disease,  acute  bronchial  symptoms 
come  on,  fever,  dyspnoea,  and  a  most  severe  straining  cough,  cyanosis, 
anxiety,  etc.,  during  which  casts  of  the  tubes  are  expectorated.  Then 
the  symptoms  subside,  and  afterward  only  those  symptoms  pertaining 
to  the  chronic  malady  are  experienced,  until  there  occurs  a  return  of  the 
paroxysms.  In  some  cases,  during  a  long  time — a  year — there  may  be 
discharged  every  few  days  casts  ;  in  other  cases  the  attacks  may  occur 
two  or  three  times  a  year.f  When  the  attacks  happen  at  longer  inter- 
vals, the  symptoms  are  apparently  more  acute  and  severe. 

Course,  Duration,  and  Termination. — The  acute  cases  run  their 
course  in  a  few  days.  The  fatal  cases  may  terminate  within  the  first 
week,  as  early  as  the  fourth  day,  and  none  continue  longer  than  two 
weeks.  About  one  half  of  the  cases  terminate  fatally.  In  the  fatal 
cases  the  casts  either  remain  in  situ  or  are  in  part  discharged,  or  are 
reproduced.  The  cyanosis  rapidly  deepens,  carbonic-acid  poisoning 
supervenes,  the  dyspnoea  augments,  and  the  patient  dies  asphyxiated. 
The  chronic  form  pursues  a  different  course.  The  attacks  recur  from 
time  to  time,  during  the  prolonged  existence  of  a  chronic  bronchitis, 
and  a  fatal  result  is  reached  in  an  acute  attack  with  symptoms  of  as- 
phyxia, or  by  the  changes  belonging  to  the  associated  malady.  Other 
cases  are  connected  with  phthisis,  emphysema,  etc.,  and  pursue  a  simi- 
lar course,  death  occurring  usually  in  an  acute  suffocative  attack. 

Diagnosis. — Until  the  characteristic  casts  have  been  discharged,  it 
will  be  impossible  to  distinguish  these  attacks  from  those  of  capillary 
bronchitis.  As  there  are  no  symptoms  of  laryngeal  stenosis,  bronchial 
will  be  readily  separated  from  laryngeal  croup.     A  careful  considera- 

*  "  Transactions  of  tbe  Pathological  Society,"  vol.  xi,  p.  23. 
f  Ibid.,  p.  24. 


414  DISEASES  OF  THE  RESPIRATORY  ORGANS. 

tion  of  the  history  of  the  case  will  prevent  this  disease  being  con- 
founded with  a  foreign  body  in  the  air-passages,  the  symptoms  being 
much  the  same  in  both.  It  is  to  be  distinguished  from  catarrhal 
pneumonia  by  the  changes  in  the  sonority  of  the  lungs  caused  by  the 
latter,  but  a  suspension  of  judgment  will  be  necessary  until  the  casts 
are  expectorated  in  those  cases  of  croupous  bronchitis  occurring  in  the 
course  of  chronic  pulmonary  affections. 

Prognosis. — Opinions  must  be  expressed  with  caution  in  any  case 
of  the  acute  type,  as  fifty  per  cent,  prove  fatal.  In  chronic  cases  the 
prognosis  is  grave,  because  in  so  many  of  them  lesions  exist,  which 
must  eventually  destroy  life.  The  prognosis  is  favorable,  however,  in 
the  chronic  cases  without  complications,  as  recovery  takes  place  in  a 
majority  of  them.  The  prognosis  is  rendered  grave  by  these  indica- 
tions :  severe  dyspnoea,  cyanosis,  stupor,  high  fever,  great  extent  of 
the  surface  affected  in  the  lungs,  the  extremes  of  age,  little  vigor  of 
constitution,  and  bad  hygienic  surroundings. 

Treatment. — ^As  the  extreme  urgency  of  the  symptoms  depends 
largely  on  the  obstruction  by  the  false  membrane  preventing  the  access 
of  air,  the  first  requisite  is  to  dislodge  and  remove  this  obsti'uction. 
Active  emesis  is  the  most  effective  means  for  immediate  result,  and  the 
most  efficient  emetic  is  apomorphia,  which  should  be  injected  hypoder- 
matically.  Kext  to  this  is  the  subsulphate  of  mercury,  which  acts 
promptly  without  j^roducing  depression.  Tartar  emetic  is  too  depress- 
ing, but  it  may  be  employed  in  the  absence  of  the  other  agents.  Sul- 
phate of  zinc  is  safe  and  effective.  The  repetition  of  the  emetic  is 
determined  by  the  dyspnoea  and  cyanosis.  Softening  the  false  mem- 
brane by  inhalation  of  the  vapor  of  water,  especially  of  lime-water,  is 
highly  serviceable.  Merely  disengaging  steam  in  the  apartment  is 
useful,  but  the  utility  of  the  application  is  greatly  enhanced  by  the 
addition  of  lime.  The  domestic  method  of  producing  vapor  and  ato- 
mizing lime  is  an  excellent  plan.  This  consists  in  slaking  freshly- 
burned  lime,  the  patient  inhaling  the  vapor  as  it  arises.  Lime-water 
may  be  atomized  in  the  ordinary  way.  Such  softening  and  solvent 
applications  should  precede  the  emetic. 

Great  good  has  been  accomplished  in  these  cases  by  the  adminis- 
tration of  the  iodides,  with  alkalies.  The  author  strongly  urges  the 
use  of  the  iodide  and  carbonate  of  ammonia,  in  small  doses  every  hour 
or  two.  It  is  highly  important  to  prevent  a  recurrence  of  the  seizures. 
Remedies  having  a  direct  effect  on  the  bronchial  mucous  membrane, 
because  eliminated  by  it  in  part,  at  least,  afford  the  best  prospect  of 
relief.  These  remedies  are  the  iodides,  the  balsams  and  oils,  as  copaiba, 
turpentine,  eucalyptol,  etc.,  which  should  be  perseveringly  administered 
for  a  long  time.  The  effect  of  these  remedies  is  aided  by  arsenic,  which 
should  also  be  given  persistently.  The  complications  of  croupous  bron- 
chitis should  be  treated  in  accordance  with  the  requirements  of  each  case. 


STENOSIS  OF  THE  BRONCHI.  415 

STENOSIS  OF  THE   TRACHEA  AND  BRONCHI. 

Definition. — By  stenosis  is  meant  a  narrowing  or  contraction  of  the 
trachea  or  bronchi,  produced  by  obstruction  within  and  by  pressure 
from  without. 

Causes. — The  trachea  or  the  bronchi  are  narrowed  by  interior  ob- 
structions and  by  exterior  pressure.  In  the  second  group  are  in- 
cluded enlarged  thyroid  or  goitre  ;  swollen  lymphatic  glands  at  the 
hilus  of  the  lungs  and  the  bifurcation  of  the  trachea  ;  aneurism  of 
the  arch  of  the  aorta,  especially  of  the  concave  and  posterior  arch  ; 
tumors,  abscesses,  etc.,  of  the  mediastinum  ;  and  cancer  of  the  lung. 
In  the  first  group  are  cicatrices,  indurations,  and  adhesions ;  neo- 
plasms or  new  formations  ;  inflammation  and  thickening  of  the 
walls,  etc. 

Symptoms. — So  far  as  the  symptoms  are  concerned,  the  cause  of 
the  obstruction  is  of  little  moment.  The  most  obvious  symptom  of 
stenosis  is  difficulty  of  breathing,  but  not  the  kind  of  difficulty  pro- 
duced by  emphysema,  capillary  bronchitis,  etc.,  which  is  expiratory, 
whereas  that  due  to  this  disorder  is  inspiratory.  When  there  is  great 
difficulty,  all  of  the  accessory  muscles  of  respiration  are  brought  into 
action  to  fill  the  lungs,  but  expiration  is  easy  and  unobstructed.  Not- 
withstanding the  strong  efforts  put  forth  to  fill  the  lungs,  this  is  not 
accomplished,  and  hence  more  or  less  rarefaction  of  the  air  in  the 
lungs  takes  place,  so  that  on  inspiration,  instead  of  expanding,  certain 
parts  of  the  chest  are  drawn  in,  viz.,  the  lower  part  of  the  sternum 
and  the  inferior  ribs.  The  movements  of  the  larynx  are  very  slight  in 
tracheal  and  bronchial  stenosis,  and  very  fi-ee  in  stenosis  of  the  larynx. 
A  peculiar  whistling,  wheezing,  crowing,  or  musical  note  is  produced 
by  stenosis,  and  the  sound  of  expiration  is  higher  in  pitch  than  that 
of  inspiration.  If  the  obstruction  is  sufficiently  high  up  in  the  tra- 
chea, the  vibration  in  the  column  of  air  may  be  transmitted  to  the 
walls  of  the  organ,  producing  a  defined  thrill.  The  voice  is  weak  and 
muffled,  because  of  the  interruption  in  the  passage  of  air  to  the  vocal 
cords.  The  vesicular  murmur  is  also  weakened,  obscured  by  the  tra- 
cheal or  bronchial  sounds,  or  absent.  This  change  may  exist  in  one 
lung  only,  if  a  bronchus  is  obstructed.  If  the  stenosis  is  in  one  bron- 
chus only,  the  movements  of  the  corresponding  side  of  the  thorax  are  les- 
sened ;  the  vesicular  murmur  is  diminished,  obscured  or  abolished,  and 
there  are  loud  whistling,  sonorous,  and  wheezing  sounds,  with  more  or 
less  thrill,  while  the  sonority  of  the  corresponding  lung  is  undiminished. 
The  healthy  lung  having  an  increased  amount  of  work  to  do,  there  is 
more  or  less  expansion,  the  movements  are  also  greater,  and  the  dia- 
phragm is  pushed  down  somewhat.  A  laryngoscopic  examination 
separates  laryngeal  from  tracheal  stenosis,  and  imder  favorable  circum- 
stances indicates  the  position  and  character  of  the  latter.     The  ration- 


416  DISEASES   OF   THE  EESPIRATORY   ORGANS. 

al  symptoms  are  those  of  difficulty  of  breathing  and  obstruction  to  the 
entrance  of  air.  The  face  is  anxious,  the  alae  of  the  nose  work,  the 
skin  is  covered  with  a  sweat,  and  there  is  constantly  present  a  sense  of 
the  need  of  air.  Besides  this  constant  difficulty  of  breathing,  the 
severity  of  which  depends  on  the  amount  of  the  stenosis,  there  now 
and  then  occur  acute  exacerbations  of  dyspnoea,  due  either  to  a  fresh 
catarrh,  to  a  sudden  increase  of  the  compressing  force,  but  especially 
to  an  asthmatic  attack.  The  ordinary  rate  of  difficulty  of  breathing 
may  continue  uniform  for  a  long  period  ;  but  toward  the  end  suffo- 
cative attacks  come  on,  which  are  at  first  separated  by  considerable 
intervals  of  time,  but  become  nearer  gradually,  and  life  is  ended  by 
them,  or  by  an  intercurrent  pneumonia. 

Course,  Duration,  and  Termination. — The  clinical  history  is  usually 
divided  into  three  stages  :  the  first  consists  of  the  disturbance  pro 
duced  by  the  growth  of  the  obstruction  ;  the  second,  the  period  of 
difficulty  of  breathing  and  the  other  symptoms  due  to  the  completed 
obstructing  cause,  which  may  continue  for  a  long  time  ;  the  third, 
consisting  of  the  final  suffocative  attacks.  The  duration  is  protracted, 
and  can  not  be  expressed  in  definite  numbers.  The  ultimate  termina- 
tion of  a  large  proportion  is  death  ;  many  cases  may  continue  for  years 
without  apparently  interfering  with  health,  but  these  are  exceptional 
cases.  Cerebral  symptoms — coma — may  appear  toward  the  end.  Death 
may  be  caused  by  pneumonia,  oedema  of  the  lungs,  etc.  Sometimes 
death  occurs  suddenly  without  the  warning  afforded  by  severe  dysp- 
noea, caused  by  the  rupture  of  an  aneurism,  of  an  abscess,  or  rarely 
without  any  apparent  cause. 

Treatment. — The  therapeutical  management  is  concerned  with  the 
cause  of  the  stenosis,  and  need  not,  therefore,  be  considered  here. 


ASTHMA. 

Definition. — This  term  has  been  applied  to  various  morbid  states, 
characterized  by  spasmodic  difficulty  of  breathing,  but  it  should  be 
restricted  to  an  independent,  substantive  affection  occurring  paroxys- 
mally,  without  any  morbid  alteration  of  the  breathing  organs,  and  con- 
sisting in  acute  dyspncea,  lasting  some  hours,  and  terminating  in 
health.  It  is  appropriately  divided  into  the  idiopathic  and  syrapto- 
matic. 

Causes. — Various  theories  of  asthma  have  been  proposed.  With- 
out occupying  space  with  details,  it  will  suffice  to  state  that  asthma 
is  a  neurosis  of  the  breathing  apparatus,  and  like  other  neuroses 
arises  from  sources  of  disturbances  in  the  nervous  system,  central  and 
peripheral.  Like  other  neuroses,  the  conditions  of  the  nervous  system 
necessary  to  its  development  may  be  inherited.  Nothing  is  more  com- 
mon than  the  occurrence  of  this  malady  in  different  generations  and 


ASTHMA.  417 

branches  of  a  family — the  author  has  known  of  many  examples. 
Asthma  alternates  with  other  nervous  affections — with  hemicrania, 
epilepsy,  and  angina  pectoris.  Asthma  also  alternates  with  affections 
of  the  skin — with  urticaria,  for  example  ;  and  succeeds  to  eruptions  of 
the  skin,  of  the  herpetic  kind  (Waldenburg).  The  pressure  of  enlarged 
lymjDhatics  on  the  pneumogastric  nerve  has  excited  attacks.  Various 
peripheral  irritations  induce  asthmatic  seizures.  Evil  intelligence,  the 
association  of  ideas  as  connected  with  particular  localities,  and  other 
moral  causes,  will  excite  attacks.  Curious  examjjles  are  related  in 
regard  to  the  influence  of  local  associations :  thus  attacks  occur 
on  one  floor  of  a  house,  and  not  another ;  on  one  side  of  a  street, 
and  not  the  other,  etc.  Distention  of  the  stomach,  indigestion,  and 
flatulence,  nasal  polypi,  certain  odors,  dust  of  a  peculiar  kind,  pollen 
of  plants,  etc.,  will  excite  attacks.  The  mechanism  is  plain.  In 
the  case  of  intestinal  irritation,  the  end-organs  of  the  pneumogas- 
tric are  acted  on,  the  impression  is  communicated  to  the  pneumogas- 
tric nucleus,  and  reflected  over  the  bronchial  and  pulmonary  branches 
of  the  vagus.  In  the  case  of  affections  of  the  nasal  mucous  mem- 
brane,  the  filaments  of  the  fifth  nerve  receive  the  impression,  and, 
as  the  nucleus  of  the  fifth  and  of  the  pneumogastric  lie  in  close  juxta- 
position, and  are  intimately  associated  in  function,  disturbance  in 
the  one  is  easily  and  quickly  transferred  to  the  other.  Of  this  rela- 
tion numerous  examples  exist.  Asthma  is  more  common  in  men  than 
in  women  :  according  to  Hyde  Salter,  of  one  hundred  and  fifty-three 
asthmatics  tabulated  by  him,  one  hundred  and  two  were  men,  and 
fifty-one  were  women.  The  disproportion  is  greater  in  advanced  life. 
Asthma  is  common  in  childhood  and  up  to  middle  age,  but  occurs  at 
all  ages.  It  is  rather  more  common  among  the  well-to-do  classes. 
Surroundings  have  but  little  influence,  unless  a  predisposition  exists. 
Change  of  locality  has  a  remarkable  influence  on  asthma,  but  the  con- 
ditions of  climate  which  prove  favorable  are  most  diverse.  Some  do 
better  in  the  heart  of  a  great  city,  others  on  a  dry  and  elevated  pla- 
teau, others  in  a  humid  valley.  Mental  and  moral  influences  are  more 
potent  than  mere  climatic  peculiarities. 

Pathogeny. — As  asthma  is  a  neurosis,  there  are  no  anatomical 
changes  peculiar  or  essential  to  it.  There  are,  it  is  true,  morbid  states 
associated  with,  but  are  not  necessary  to  it.  Bronchial  catarrh  is  often 
found,  also  emphysema,  but  these  are  sequelse  or  results,  rather  than 
a  part  of  the  disease.  During  the  existence  of  the  asthmatic  paroxysm, 
an  intense  congestion  has  been  seen  on  laryngoscopic  examination. 
There  are,  at  present,  two  dominant  theories  of  the  pathogeny  of  the  , 
asthmatic  seizures  ;  the  theory  of  tonic  spasm  of  the  diaphragm,  pro- 
pounded by  Wintrich  ;  the  theory  of  spasm  of  the  bronchial  muscles, 
which  is  the  oldest  theory,  but  has  the  support  of  Salter,  "Williams,  and 
Trousseau,  and  is  now  sustained  by  the  remarkable  investigation  of 
27 


418  DISEASES  OF  THE  EESPIRATORY  ORGANS. 

Professor  Paul  Bert.  The  new  theory  of  Leyden  *  has  attracted  at- 
tention by  its  singularity.  He  finds  in  the  expectoration  brownish 
cells  undergoing  granular  degeneration,  between  which  are  colorless, 
extremely  small  but  pointed,  octahedral  crystals,  some  readily  visible, 
others  requiring  immersion  lenses  to  find  them.  These  crystals  have 
been  examined  by  Salkowski,f  with  the  result  to  show  that  they  must 
be  composed  of  a  material  analogous  to  mucin.  Leyden  supposes  the 
asthmatic  paroxysm  to  be  determined  by  a  reflex  spasm  of  the  muscles 
of  the  bronchial  tubes,  induced  by  the  irritation  of  the  terminal  fila- 
ments of  the  vagus  by  these  minute  crystals.  A  more  recent  and  the 
latest  theory  is  that  of  Weber  (Riegel  I ),  which  supposes  the  conciir- 
rence  of  a  number  of  factors  in  causing  asthma,  such  as  bronchial 
spasm,  catarrh  of  the  tubes,  tonic  spasm  of  the  diaphragm,  cardiac 
lesions,  etc.,  which  is,  in  fact,  a  combination  of  the  previous  theories, 
and  is,  probably,  the  nearest  approach  to  a  true  hypothesis  in  that  it 
adopts  all  the  presumed  causes. 

Symptoms. — The  first  attack  is  sudden,  but  the  succeeding  attacks 
are  preceded  by  prodromes,  the  significance  of  which  presently  be- 
comes apparent  to  the  sufferer.  These  prodromes  are  usually  acute 
coryza,  some  bronchial  irritation,  headache,  and  general  malaise;  or 
the  preliminary  symptoms  may  be  those  of  indigestion — acidity,  pyro- 
sis, flatulence,  hiccough,  sneezing,  etc.  The  first  attack  is  nocturnal. 
The  victim,  after  some  uneasy  sleep,  is  suddenly  aroused  by  an  intense 
anguish  in  his  chest ;  he  is  stuffed  up  and  struggles  for  air,  jumps  from 
the  bed  and  rushes  to  the  window,  or  he  sits  up,  leaning  forward  on  his 
arms,  and  uses  all  his  strength  in  the  effort  to  get  more  air.  The 
breathing  is  accompanied  with  loud  wheezing,  the  face  becomes  flushed 
and  at  the  same  time  cyanosed,  and  is  bathed  in  perspiration,  the 
eyes  stare,  the  eyeballs  protrude,  and  the  muscles  of  the  neck  start 
prominently  up,  as  they  are  called  on  to  aid  in  the  effort  to  get  air. 
The  difficulty  of  breathing  soon  reaches  a  point  that  the  inspiration  is 
nothing  but  a  gasp,  the  lips  become  pallid,  the  cyanosis  deepens,  and 
it  appears  to  the  patient  that  every  minute  must  be  his  last.  After 
some  minutes  or  hours  the  respiration  becomes  a  little  easier,  more  air 
enters  the  lungs,  the  cyanosis  subsides,  and  gradually  the  paroxysm 
ceases.  Eructations  of  gas  give  great  relief  as  the  breathing  becomes 
easy,  and  the  bronchial  tubes  pour  out  an  abundant  mucus  secretion, 
the  expectoration  of  which  also  contributes  to  the  ease  of  respiration 
now  rapidly  increasing.  A  free  urinary  discharge  also  takes  place,  the 
urine  being  pale,  and  of  low  specific  gravity.  The  patient,  exhausted 
with  the  violence  of  his  efforts  to  get  air,  sinks  into  a  profound  sleep, 
and  is  bathed  in  perspiration.     The  whole  duration  of  an  attack  rarely 

*  Virchow's  "  Archiv,"  vol.  liv,  p.  324,  "  Zur  Kenntniss  dcs  Bronchial-Asthma." 

t  Ibid.,  p.  844. 

■\.  /icmssen's  "  Cyclopa3dia,"  vol.  iv. 


ASTHMA.  419 

exceeds  six  hours,  and  may,  indeed,  be  no  more  than  one  hour.  On 
the  following  day  there  are  experienced  muscular  soreness,  languor, 
and  debility,  but  all  unpleasant  feelings  subside  and  disappear  in 
twenty-four  hours,  and  a  normal  condition  is  maintained  until  the  next 
attack.  Instead  of  a  single  paroxysm  there  may  be  only  slight  remis- 
sions, and  one  attack  succeed  to  another,  with  exacerbations,  so  that 
the  patient  can  not  lie  down  at  all,  can  take  but  little  food,  and  is,  after 
some  days  of  suffering,  utterly  exhausted.  The  attacks  are  not  exclu- 
sively nocturnal,  but  do  sometimes  occur  during  the  day.  A  diurnal 
attack  must  be  the  rule  in  those  cases  brought  on  by  the  inhalation  of 
some  kinds  of  dust,  gas,  or  vapor,  as  from  powdered  ipecac,  etc.  On 
percussion,  the  sonority  of  the  thorax  is  increased  in  the  vertical  , 
diameter  from  one  to  two  inches,  and  also  transversely,  and  does  not  f 
change  either  on  inspiration  or  expiration.  The  percussion-note  is  ' 
highly  resonant  all  over  both  lungs,  and  has  somewhat  the  tympanitic 
quality.  The  "bandbox-tone,"  by  which  it  is  described  by  Bam- 
berger, is  eminently  characteristic.  The  vesicular  murmur  is  either 
absent  or  greatly  enfeebled,  or  obscured  by  the  loud,  wheezing,  whis- 
tling, sibilant  sounds.  During  expiration  the  sibilant,  sonorous,  whis- 
tling, cooing,  sighing  sounds  are  more  pronounced  and  of  longer  dura- 
tion. Toward  the  close  of  an  attack  moist  sounds  occur.  The  expla- 
nation of  the  physical  signs  present  in  an  attack  of  asthma  is  afforded 
in  the  condition  of  the  chest.  The  diaphragm  is  depressed  below  its 
ordinary  position  by  tonic  contraction  ;  the  chest,  which  assumes  a  dis- 
tended, globular  shape,  is  fixed  in  the  position  of  forced  inspiration. 
The  lungs  are  filled  with  air,  but  it  is  residual  air,  and  is  not  renewed  ; 
and,  notwithstanding  the  effort  put  foi'th  by  the  patient,  the  little  air 
which  can  be  introduced  only  adds  to  the  distention.  Expiration  is 
prolonged,  laborious,  wheezing,  and  much  more  so  than  inspiration. 
Spasm  of  the  muscular  fibers  of  the  bronchi  is  perhaps  only  one  ele- 
ment in  the  obstruction  to  the  expiration  of  air  ;  tonic  contraction  of 
the  diaphragm  contributes  not  a  little  to  the  result.  The  fullness  of  the 
cephalic  veins  and  the  cyanosis  and  lividity  of  the  face  are  due  to  the 
contraction  of  the  cervical  muscles  preventing  the  return  of  blood,  and 
to  deficient  oxygenation  of  the  blood.  While  the  face  is  flushed  and  the 
head  hot,  the  feet  are  cold.  The  sputa  are  wanting  in  the  beginning, 
but  appear  abundantly  at  the  close  of  the  paroxysm  ;  they  are  frothy, 
grayish-white,  or  reddish-white  if  mixed  with  blood,  and  consist  of 
mucus  corpuscles,  cylindrical  and  ciliated  epithelium,  and  peculiar 
"  yellowish-green  clumps  "  in  which  are  imbedded  Leyden's  crystals. 

Course,  Duration,  and  Termination.  —  Asthma  is  an  essentially 
chronic  disease,  not  incompatible  with  long  life,  and  with  good,  even 
vigorous  health,  during  the  intervals  between  the  seizures.  The  par- 
oxysms last  from  two  to  six  hours,  but  sometimes  they  persist  for 
days.     Of  itself,  asthma  is  never  fatal  to  life,  but  changes  in  the  or- 


420  DISEASES  OF  THE   RESPIRATORY    ORGANS. 

ganism  are  gradually  effected  by  the  disturbance  in  the  respiratory 
function,  which  may  cause  death.  Emphysema,  dilated  right  cavities, 
dropsy,  or  cerebral  haemorrhage,  may  be  brought  on  by  the  long-contin- 
ued operation  of  the  cause.  Much  depends  on  the  number  of  the  par- 
oxysms. There  may  be  very  few  or  very  many.  They  may  be  mild 
at  first,  and  become  more  severe,  or  they  may  commence  and  persist 
with  the  greatest  severity.  They  may  disappear  suddenly,  and  never 
occur  again.  According  to  the  behavior  of  the  disease  will  vary  the 
sequelge.  Asthma  may  also  occur  as  a  complication  of  some  existing 
disease — as,  for  example,  emphysema,  chronic  bronchitis,  etc. 

Diagnosis. — It  is  not  possible  to  mistake  asthma  when  the  history 
is  known.  The  first  attack  may  be  confounded  with  oedema  of  the 
glottis  or  spasm,  paralysis  of  the  vocal  cords,  and  stenosis  of  the  trachea. 
Laryngoscopic  examination  may  serve  to  differentiate  at  once,  by 
Tecognition  of  the  lesion.  The  most  important  means  of  determining, 
besides  the  history  and  the  direct  exploration  of  the  larynx  and  trachea, 
is  the  character  of  the  dyspnoea.  In  laryngeal  or  tracheal  obstruction, 
the  dyspnoea  is  inspiratory,  in  asthma  it  is  expiratory.  In  cedema  of 
the  glottis,  while  inspiration  is  difficult,  expiration  is  easy  and  unob- 
structed ;  with  inspiration  there  is  a  loud  sibilant  or  crowing  noise, 
and  expiration  is  silent. 

Treatment. — To  relieve  the  paroxysm  is  the  most  pressing  duty. 
There  is  no  medication  so  effective  as  the  hypodermatic  injection  of 
morphia  (from  -^^  gr.  to  ^  gr.).  An  efficient  dose  of  chloral  hydrate  is 
often  equally  effective  (3  j —  3  ss.).  As  soon  as  the  patient  comes  un- 
der the  influence  of  either  remedy,  the  difficulty  of  breathing  begins 
to  subside.  The  best  results  are  obtained  from  a  combination  of  the 
two  remedies — morphia  hypodermatically  and  chloral  by  the  stomach — 
but  in  smaller  quantity  than  when  administered  separately.  Nitx'ite  of 
amyl  (by  inhalation,  three  to  five  minims)  sometimes  affords  relief,  but 
its  action  is  uncertain,  and  when  it  fails  to  relieve  it  may  occasion  ex- 
treme distress.  In  many  cases  iodide  of  potassium,  in  full  doses,  will 
arrest  the  paroxysms  very  remarkably.  From  fifteen  to  twenty  grains, 
every  two,  three,  or  four  hours,  are  usually  required.  It  is  better  prac- 
tice to  give  iodide  with  bromide  of  potassium,  and  to  each  dose  of  the 
solution  may  also  be  added  a  drop  or  two  of  Fowler's  solution  of  ar- 
senic. This  combination  is  to  be  commended,  especially  in  the  cases 
which  persist  for  some  days.  Much  relief  is  affoi-ded  by  fumes  of  stra- 
monium and  other  narcotics  ;  old  asthmatics  often  depend  on  fumi- 
gation to  the  exclusion  of  all  other  remedies.  Pastils,  or  cigarettes 
containing  leaves  of  belladonna,  stramonium,  tobacco,  grindelia,  and 
poppy,  in  equal  portions,  steeped  in  a  saturated  solution  of  niter  and 
dried,  are,  after  ignition,  inhaled,  as  they  ai'ise,  or  a  mass  of  the  leaves 
is  ignited  in  a  small  apartment  which  may  be  filled  with  the  fumes. 
There  are  a  great  many  proprietary  pastils  sold,  but,  under  what  name 


ASTHMA.  421 

soever  they  appear,  the  composition,  with  unimportant  differences,  is 
about  as  stated  above.  Belladonna-leaves  saturated  with  nitre  afford 
as  good  results,  usually,  as  the  more  complicated  pastils.  Simple 
niter-paper  gives  ease  for  a  time.  The  new  California  remedy,  grin- 
delia  robusta,  has  undoubtedly  great  power  to  arrest  a  paroxysm  of 
asthma.  Three  to  live  grains  of  the  extract  or  the  fluid  extract  (  3  ss.) 
can  be  given  every  hour  or  two.  Grindelia  is  often  useful  as  a  fumi- 
gant.  The  debility  caused  by  asthmatic  paroxysms  is  best  removed 
by  quinia  and  iron,  the  former  in  considerable  doses.  This  practice  is 
especially  to  be  commended  when  the  paroxysms  recur  frequently.  To 
prevent  a  return  of  the  attacks,  arsenic  is  very  useful,  and  is  most 
effective  in  combination  with  the  iodides.  In  debilitated  subjects, 
quinia,  arsenic,  and  belladonna  may  be  given  steadily  for  some  weeks 
or  months,  as  the  case  may  be.  Asthma,  like  other  neuroses,  is  capri- 
cious in  its  behavior  toward  remedies.  The  remedy  succeeding  at  one 
time  may  fail  utterly  at  another  time,  so  that  the  treatment  must  be 
varied  accordingly.  Hence  it  is  necessary  to  be  fertile  of  resources 
in  the  treatment  of  this  disease.  Besides  the  methods  of  treatment 
already  mentioned  which  are  most  approved,  there  are  others  less 
desirable  which  should  receive  some  notice.  Nauseants,  as  ipecac,  tar- 
tar emetic,  and  lobelia,  afford  relief  by  inducing  relaxation  consequent 
on  the  nausea.  When  there  is  much  catarrh,  or  the  attack  of  asthma 
is  due  to  an  acute  catarrh,  good  results  are  obtained  by  small  doses  of 
tartar  emetic  {^^  gr.)  with  morphia  (jV)-  ^  ^^w  drops  of  wine  of  ipi- 
cac  (five  to  ten)  every  five  minutes,  until  some  nausea  is  experienced, 
may  lessen  the  oppression  remarkably.  During  the  paroxysm,  nause- 
ant  doses  of  lobelia  (m  xv. —  3  ss.  of  the  fluid  extract)  are  very  effective 
in  stopping  the  dyspnoea.  Besides  the  very  disagreeable  effects  of  the 
remedies  of  this  group,  in  producing  nausea  and  depression,  there  is 
such  debility  caused  by  them  that  days  are  necessary  to  recover  the 
usual  stamina. 

The  application  of  ammonia  to  the  posterior  wall  of  the  pharynx  is 
practiced  by  the  French,  but  this  practice  is  strongly  condemned  by 
Jaccoud.  He,  however,  permits  the  application  of  ammonia  by  im- 
pregnating the  air  of  the  apartment.  The  inhalation  of  oxygen  and  of 
compressed  air  relieves  the  breathing  somewhat,  but  ether  and  chloro- 
form are  much  more  effective.  Indeed,  the  former  should  always  be 
given  a  trial. 

In  the  treatment  of  asthma  thei'e  is  no  point  of  greater  importance 
than  careful  regulation  of  the  diet.  Hyde  Salter  much  insists  on  this, 
and  the  author  has  had  abundant  confirmatory  observation.  The  diet 
should  be  light  and  easily  digestible,  and  as  little  bulky  as  possible. 
It  should  consist,  therefore,  chiefly  of  animal  food,  and  to  this  may  be 
added  a  little  fruit  and  a  few  of  the  succulent  vegetables,  but  starchy 
and  saccharine  substances  and  milk  should  be  excluded.     In  this  pro- 


422  DISEASES   OF   THE   EESPIRATORY   ORGANS. 

hibition  bread  is  included,  as  it  is  particularly  apt  to  disagree.  Articles 
of  diet  that  are  fried,  pastry,  cakes,  and  sirup,  etc.,  are  highly  objec- 
tionable. Meats  should  be  broiled  or  roasted.  Boiled  meats  and  soups 
are  improper.  There  should  be  as  little  fluid  drunk  at  meals  as  pos- 
sible, but  a  little  black  coffee  may  be  allowed  at  breakfast. 


DISEASES   OF  THE   LARYNX— ACUTE    CATARRH   OP  THE   LAR- 
YNX— LARYNGITIS. 

Definition. — By  acute  catarrh  of  the  larynx  is  intended  an  inflam- 
mation involving  the  mucous  membrane — a  catarrhal  inflammation. 
There  is  also  a  chronic  form  of  the  disease — chronic  inflammation. 

Causes. — The  mucous  membrane  of  the  larynx  is  in  a  position  to  be 
quickly  and  easily  affected  by  external  agents  of  a  gaseous  or  aeriform 
kind — such  as  ammoniacal  gas,  chlorine,  tobacco-fumes,  etc.  Very  fine 
solid  particles  may  be  carried  in  the  air  in  sufficient  quantity  to  excite 
an  irritation  of  the  laryngeal  mucous  membrane.  But  the  organ  is 
more  frequently  affected  by  the  condition  of  the  atmosphere  itself. 
The  long-continued  inspiration  of  air  contaminated  by  respiration  is 
very  apt  indeed  to  cause  congestion  of  the  mucous  membrane,  espe- 
cially when  to  this  is  added  the  sudden  contact  of  cold  air.  Too  pro- 
longed exertion  of  the  voice  may  also  excite  a  catarrhal  inflammation, 
especially  when  the  exertion  is  made  in  the  open  air.  "  Taking  cold  " 
is  a  fruitful  cause  of  laryngitis.  There  may  be  an  extension  of  trouble 
from  the  pharynx  and  from  the  face  (erysipelas).  Influenza  may  ex- 
tend to  the  mucous  membrane  of  the  larynx.  Inflammation  of  the 
larynx  is  not  an  infrequent  complication  in  the  course  of  the  infectious 
diseases.  Climate  has  an  unquestionable  influence  ;  humid,  cold,  and 
variable  climates  increase  the  disposition  to  affections  of  the  larynx, 
while  warm  and  equable  climates  lessen  the  tendency  to  these  diseases. 
Affections  of  the  larynx  occur  at  all  ages,  and  both  sexes  are  equally 
liable  in  proportion  to  their  exposure  to  the  causes. 

Pathological  Anatomy. — In  the  mildest  cases  there  is  a  transient 
hypersemia  of  the  mucous  membrane — in  certain  situations — over  the 
arytenoid  cartilages,  the  ventricular  bands,  the  posterior  ends  of  the 
vocal  cords,  and  the  space  between  the  arytenoid  cartilages.  In  more 
severe  cases  there  is  a  good  deal  of  swelling  as  well  as  injection  of  the 
ventricular  bands,  the  epiglottis,  the  ary-epiglottidean  folds,  and  the 
inter- arytenoid  space,  etc.  The  color  in  severe  cases,  instead  of  being 
reddish,  is  a  dark,  reddish-brown. 

Symptoms. — In  the  mildest  cases  there  is  no  constitutional  disturb- 
ance. The  local  symptoms  consist  in  heat,  rawness,  and  tickling,  re- 
ferred to  the  larynx  and  pharynx.  When  the  thyroid  cartilages  are 
pressed,  unusual  soreness,  irritation,  and  severe  pain  are  experienced. 
There  are  also  present  dryness,  and  a  feeling  of  a  foreign  body  stick- 


LARYNGITIS.  423 

ing  in  the  throat.  Swallowing  causes  pain  by  the  upward  movement 
of  the  larynx,  and  by  the  pressure  of  the  bolus  on  the  larynx  as  it  de- 
scends to  the  stomach.  In  the  more  severe  cases  the  onset  of  the  dis- 
ease is  announced  by  some  chilliness  and  general  malaise,  followed  by 
moderate  fever,  anorexia,  etc.,  for  several  days.  Cough  occurs  at  once, 
and  it  is  noisy,  harsh,  hoarse,  or  toneless  ;  or,  in  children  especially, 
has  a  ringing,  sonorous,  so-called  "  croupy  "  character.  The  cough  is 
dry,  and  produces  a  sensation  in  the  larynx  as  of  scratching  over  a 
raw  surface  ;  but  in  a  short  time  secretion  is  poured  out,  and  then  the 
cough  has  a  loose  character.  At  first  some  frothy  mucus  is  expecto- 
rated ;  it  may  be  streaked  with  blood  occasionally,  but  in  the  rare 
hseraorrhagic  form  pure  blood  may  be  expectorated.  The  sputa,  soon 
assume  the  appearance  of  muco-pus,  the  pus  elements  predominating  ; 
and  it  contains  also  cast-off  ciliated  ei^ithelium,  young  cells,  etc.  At 
first  the  voice  is  thick,  and  becomes  hoarse  on  talking  ;  but  as  the  case 
progresses  the  hoarseness  deepens,  and  at  length  there  is  aphonia. 
Dyspnoea  rarely  occurs  to  adults  in  simple  mucous  laryngitis,  but  in 
children  spasm  of  the  glottis  may  come  on,  when  there  is  extreme 
dyspnoea  in  brief  paroxysms.  But,  as  this  disorder  will  be  discussed 
in  a  separate  section,  its  consideration  as  a  symptom  of  laryngitis  is 
postponed.  A  sense  of  oppression  and  need  of  air  is  caused  if  there  be 
much  swelling  of  the  vocal  cords  or  ventricular  bands  in  the  case  of 
adults — a  condition  of  things  not  apt  to  occur  unless  there  be  some 
effusion  into  the  sub-mucous  connective  tissue.  Besides  hoarseness, 
which  may  end  in  aphonia,  there  may  be  various  alterations  in  the 
tone  of  the  voice,  high  pitch  or  low  pitch,  and  its  timbre  may  be 
subjected  to  corresponding  variations.  The  peculiarities  of  voice  are 
due  to  swelling  of  the  mucous  membrane,  variations  in  tension  of  the 
vocal  cords,  and  the  condition  of  the  muscles  moving  the  arytenoid 
cartilages.  The  tone  of  voice  is  hoarse  and  rough  from  swelling  of 
the  cords,  discordant  from  the  difference  in  the  rate  of  vibrations  of 
the  two  cords,  high-pitched  if  the  tension  in  the  cords  is  great,  low- 
pitched  if  the  tension  is  low  ;  or  there  is  a  double  tone,  now  high,  now 
low,  if  the  cords  vibrate  with  opposite  tension.  On  laryngoscopic 
examination  the  state  of  the  mucous  membrane,  of  the  vocal  cords, 
ventricular  bands,  etc.,  can  be  made  out,  and  the  changes  described 
verified. 

Course,  Duration,  and  Termination. — Acute  laryngitis  passes  through 
its  course  in  a  week,  if  mild  ;  but  the  more  severe  cases  may  occupy 
three  weeks  to  a  month.  Mild  as  well  as  severe  cases  may  continue 
indefinitely  by  repeated  relapses,  and  at  last  assume  the  chronic  form. 
Under  some  circumstances  a  simple  laryngitis  may  assume  formidable 
proportions  by  the  extension  to  the  sub-mucous  connective  tissue. 

Treatment. — Confinement  to  bed  for  the  more  severe  cases,  and  to 
a  uniformly  but  not  too  highly  warmed  apartment  for  the  milder  cases, 


4,24:  DISEASES   OF   THE   RESPIRATORY   ORGANS. 

is  essential.  The  air  of  the  apartment  should  be  kept  moist  by  the 
vapor  of  water  disengaged  in  it.  For  the  relief  of  the  inflamed  mu- 
cous membrane,  tincture  of  aconite-root — one  drop  for  a  child  and  two 
drops  for  an  adult  every  two  hours — is  highly  efficient.  If  there  be 
much  cough,  and  especially  if  the  cough  have  the  "  croupy  "  character, 
two  to  five  drops  of  the  deodorized  tincture  of  opium  and  one  or  two 
drops  of  fluid  extract  of  ipecac  may  be  given  together.  Application 
by  spray  douche  of  a  solution  of  morphia  to  the  throat  is  an  excellent 
means  of  relieving  cough,  but  is  not  so  generally  available  as  the  inter- 
nal administration.  A  very  minute  quantity  of  tartar  emetic,  with 
paregoric  and  sirup  of  lactucarium,  is  also  an  efficient  combination. 
A  hot  or  cold  pack  should  be  wrapped  about  the  throat  after  a  brief 
application  of  mustard  ;  and,  if  the  case  is  just  beginning,  the  feet 
should  be  placed  in  a  mustard  foot-bath.  If  there  be  a  tendency  to 
spasm  of  the  glottis,  bromides  should  be  used.  Bromide  of  potassium 
may  be  given  with  any  of  the  combinations  above  mentioned. 

Prophylaxis  is  very  important  in  the  case  of  those  who  have  fre- 
quent attacks,  especially  if  a  phthisical  tendency  exists.  They  should 
wear  flannels  and  protect  the  feet  against  dampness,  while  at  the  same 
time  they  should  avoid  warm  wraj^pings,  especially  furs  about  the 
throat.  The  tendency  to  take  cold  may  be  obviated  by  a  daily  morn- 
ing cold  sponge-bath,  and  by  keeping  up  the  general  health.  During 
a  variable  season,  taking  cold  may  be  prevented  by  the  daily  morning 
administration  of  five  to  ten  grains  of  quinia,  and  the  access  of  an 
impending  attack  may  be  prevented  by  a  full  dose  of  quinia  and  mor- 
phia (15  grs. — gr.  i-i). 


CHRONIC  LARYNGITIS— CHRONIC  CATARRH  OP  THE  LARYNX. 

Definition. —  Chronic  laryngitis  is  an  inflammation  of  the  mucous 
membrane,  less  active  in  type  than,  but  the  same  in  mode  as,  the  acute 
inflammation. 

Causes. — The  chronic  form  of  catarrhal  inflammation  of  the  larynx 
arises  under  the  same  conditions  as  the  acute  form,  or  it  succeeds  to 
an  acute,  or  is  a  result  of  repeated  acute  inflammation.  Tobacco- 
smoking,  spirit-drinking,  and  careless  use  of  the  vocal  organs  in  speak- 
ing, reading  aloud,  or  singing,  are  all  influential  causes,  the  most  impor- 
tant, in  fact,  in  our  day.  The  middle  period  of  life  and  the  male  sex 
are  predisposing  causes. 

Pathological  Anatomy. — The  changes  described  as  occurring  in  the 
acute  form  are  the  initial  lesions  in  the  chronic,  except  that  in  the  lat- 
ter the  color  is  deeper  red  or  brownish,  the  mucosa  is  more  swollen, 
and  the  submucosa  as  well  as  the  mucosa  is  thickened  and  indurated. 
Swelling  of  the  inter-arytenoid  fold  of  mucous  membrane  and  of  the 
ventricular  bands  (false  vocal  cords)   occurs  to  the  degree  that  the 


LAEYNGITIS.  425 

movements  of  the  arytenoid  cartilages  are  interfered  with,  and  conse- 
quently of  the  vocal  cords  also.  The  ej)iglottis  is  likewise  swollen 
and  thickened,  and  marked  by  enlarged  and  varicose  veins.  The  vocal 
cords  themselves  are  injected,  and  their  margins  roughened.  The 
follicles  of  the  mucous  membrane  are  enlarged  by  accumulation  of 
their  contents  in  part,  but  much  more  by  hyperplasia  of  the  surround- 
ing connective  tissue.  The  enlarged  follicles  or  glands,  more  or  less 
thickly  distributed  over  the  surface,  give  to  the  mucous  membrane  a 
granular  appearance.  Very  rarely  hyperplasia  of  the  connective  tis- 
sue underlying  the  vocal  cords  takes  place  ;  the  new  tissue  contracts, 
and  deformity,  with  stenosis,  is  the  ultimate  result. 

Symptoms. — Various  uneasy  sensations  are  felt  in  the  larynx — a 
sense  of  heat,  and  an  irritation  compounded  of  itching  and  scratching 
of  a  tender  surface  ;  this  leads  to  hawking  and  clearing  the  throat  as 
if  some  obstruction  were  present.  Exj)osure  to  cold  air  increases  these 
sensations,  but  still  more  irritating  is  prolonged  talking,  especially  in 
the  open  air,  leading  to  frequent  swallowing  of  saliva.  The  voice  is 
husky,  and  becomes  so  much  so  by  talking  that  frequent  efforts  to 
clear  the  throat  are  necessary.  The  voice  becomes  hoarse,  rasi^ing, 
and  deep,  or  it  is  high-pitched,  and  unexpectedly  drojDS  into  falsetto. 
As  much  effort  is  necessary  to  get  out  the  sounds,  these  patients  ac- 
quire a  straining  tone  and  manner,  and  now  and  then,  amid  husky  and 
hoarse,  almost  toneless  sounds,  they  utter  a  more  distinct  and  intelligible 
sound,  giving  an  eccentric  and  variegated  expression  to  the  conversa- 
tion. The  effort  required  makes  talking  very  fatiguing.  In  the  morn- 
ing the  most  severe  paroxysms  of  coughing  and  straining  are  experi- 
enced ;  the  secretion  accumulates  during  the  night,  and  it  is  detached 
with  difficulty,  so  that  much  coughing,  hawking,  and  straining  are 
necessary.  The  secretion  is  in  the  aggregate  not  considerable,  and 
consists  of  a  tenacious  mucus,  with  some  pus-corpuscles. 

Course,  Duration,  and  Termination. — It  is  a  very  chronic  malady 
and  is  subject  to  exacerbations  and  remissions.  Care  in  the  manage- 
ment of  the  organ,  and  of  the  general  health,  rest,  and  appropriate 
treatment,  bring  relief,  but  abuse  of  the  organ,  irregularities  of  life,  and 
the  absence  of  all  treatment,  will  restore  the  diseased  state  to  full  ac- 
tivity. Years  may  be  passed  in  this  way,  the  general  health  mean- 
while not  suffering  from  the  laryngeal  disease.  Cures  may  be  effected 
in  favorable  cases,  if  proper  treatment  is  carried  out  faithfully  for  a 
sufficient  period  of  time,  but  the  difficulties  in  the  treatment,  the  self- 
denial  to  be  practiced,  and  the  duration  of  the  case,  should  not  be  con- 
cealed from  the  patient. 

Treatment. — Any  effective  treatment  must  include  local  apj)lica- 
tions,  directed  by  the  laryngeal  mirror  and  by  spray.  As  there  is  a 
large  extent  of  surface  involved,  and  as  the  increased  blood-supply  is 
the  leading  pathological  factor,  the  application  of  medicated  spray  may 


426  DISEASES   OF   THE   RESPIRATORY   ORGAXS. 

be  sufficient  of  itself.  A  great  number  of  medicinal  agents  are  so  em- 
ployed— a  solution  of  tannin  (gr.  v —  §  j),  of  sulphate  or  acetate  of 
zinc  (gr.  j —  |  j),  of  chlorate  of  potassium  (gr.  v —  3  j),  of  bromide  of 
potassium  (gr.  x —  3  j),  of  nitrate  of  silver,  with  cai'e  (gr.  j —  3  j),  and 
of  morj)hia  sulphate  if  there  is  much  irritability.  Solution  of  nitrate 
of  silver  is  applied  by  the  brush  directly  to  the  interior  of  the  larynx. 
Ziemssen  recommends  in  inveterate  cases  the  solid  nitrate,  which  is 
applied  by  the  caustic-holder  directly.  Such  external  applications  as 
the  tincture  of  iodine,  the  ointment  of  the  red  iodide  of  mercury,  etc., 
are  serviceable  as  counter-irritants.  The  larynx  must  be  kept  at  rest 
as  long  as  practicable.  Taking  cold,  sudden  changes  of  temperature, 
exposure  to  draughts,  must  be  avoided.  The  general  health  must  be 
maintained  by  a  suitable  mode  of  life.  Change  from  a  variable  to  a 
more  equable,  and  from  a  humid  and  cold  to  a  warm  and  dry  climate, 
will  often  have  a  most  favorable  effect  on  the  case. 


GSDEMA   OF    THE   GLOTTIS— INFILTRATION    OF    THE    LARYNX. 

Definition. —  (Edema  of  the  glottis  means  a  serous  effusion  into  the 
sub-mucous  connective  tissue.  The  disease  or  condition  intended  by 
this  term  is  an  obstruction  to  breathing  produced  by  an  infiltration 
of  the  larynx  by  any  kind  of  fluid. 

Causes. — An  inflammation  of  the  mucosa  may  extend  to  the  sub- 
mucosa,  and  cause  oedema.  A  deep-seated  phlegmon  of  the  neck,  or 
of  the  tonsil  and  the  base  of  the  tongue,  may  involve  the  larynx  by 
the  diffusion  of  the  pus  under  the  mucous  membrane.  An  inflamma- 
tion of  the  cartilages  or  of  the  perichondrium  may  result  in  a  similar 
purulent  infiltration.  Erysipelas  of  the  face,  typhoid  fever,  or  scarla- 
tina, may  be  unexpectedly  terminated  by  a  sudden  effusion  into  the 
sub-mucous  connective  tissue.  During  the  course  of  Bright's  disease, 
oedema  of  the  glottis  may  occur,  or  this  may  be  the  first  symptom  of 
the  malady  to  attract  attention. 

Pathological  Anatomy. — The  oedema  exists  in  those  parts  containing 
the  most  abundant  and  loose  connective  tissue — in  the  ary-epiglottic 
folds,  the  glosso-epiglottic  ligament,  at  the  base  of  the  epiglottis,  and 
in  the  inter-arytenoid  space.  When  the  inferior  or  true  vocal  cords 
are  inflamed  (one  or  both),  the  cord  changes  its  color,  and  instead  of 
appearing  white,  glistening,  and  brilliant,  is  dull,  grayish-red,  or  violet- 
red,  in  patches,  the  vessels  enlarged  and  varicose.  When  oedema 
exists  without  inflammatory  changes,  the  sub-mucous  connective  tissue 
of  the  ventricular  bands  especially,  and  of  the  folds  mentioned  above, 
IS  distended  with  a  serous  fluid,  and  has  the  translucent  appearance 
of  a  fish's  swimming-bladder.  The  ventricular  bands  project  forward, 
almost  meeting  in  the  median  line,  and  shutting  from  view  above  the 
vocal  cords.     The  epiglottis  sub-mucous  tissue  may  also  be  distended 


LARYNGITIS.  427 

in  the  same  manner,  giving  to  that  organ  the  same  .pellucid  and  semi- 
transparent  appearance.  If  the  swelling  be  due  to  purulent  infiltra- 
tion, the  epiglottis,  the  aryteno-epiglottidean  folds,  and  the  ventricular 
bands,  will  be  swollen,  and  present  a  deeply  congested,  reddish-brown 
or  violet  tint,  with  here  and  there  spots  of  a  yellowish  hue.  A  very 
considerable  collection  of  pus  may  form  when  the  base  of  the  tongue, 
or  the  loose  connective  tissue  beneath  the  tonsils,  and  the  tissues  of  the 
larynx  are  simultaneously  involved.  A  serous  infiltration  sufficient  to 
cause  fatal  oedema  has  disappeared  in  the  death-agony,  or  immediately 
after,  leaving  but  small  traces  of  the  mischief  to  account  for  the  for- 
midable symptoms. 

Symptonis. — Infiltration  of  the  larynx,  succeeding  either  to  some 
inflammatory  process  in  the  neighborhood  or  of  the  larynx  itself,  or  com- 
ing on  in  the  course  of  some  constitutional  malady,  adds  its  special 
features  to  the  symptoms  of  the  preexisting  disease.  These  are  a  sen- 
sation of  distress  or  actual  pain  in  the  pharynx  and  larynx  ;  painful 
dysphagia  ;  dyspnoea  ;  or  paroxysms  of  a  suffocative  character.  The 
sensations  referable  to  the  larynx  consist  of  constant  oppression  as  if  a 
foreign  body  were  wedged  in  the  organ,  and  more  or  less  severe  sore- 
ness and  pain  shooting  through  the  whole  area  occupied  by  the  purulent 
infiltration,  if  that  be  the  cause  of  the  symptoms.  There  may  be  in 
attempts  to  swallow  only  a  sense  of  soreness  or  of  obstruction,  but  in  the 
case  of  inflammation  and  swelling  there  will  be  acute  pain.  The  feel- 
ing of  the  presence  of  a  foreign  body  and  the  accumulation  of  saliva 
incite  the  act  of  swallowing,  which  is  the  more  painful  the  more  fre- 
quently it  is  repeated.  When  there  is  extensive  infiltration,  swallow- 
ing may  become  impossible,  and  then  the  saliva  is  permitted  to  dribble 
from  the  mouth.  At  first  the  cough  is  dry,  rather  harsh,  and  somewhat 
resonant,  but  as  the  swelling  proceeds  it  becomes  stridulous  and  sup- 
pressed. The  peculiar  difficulty  in  inspiration  is  the  most  character- 
istic symptom.  At  first  a  slight  sense  of  stuffing  of  the  larynx  and 
huskiness  of  the  voice  are  experienced,  but  the  sensation  of  stuffing 
grows  tighter,  and  the  inspiration  becomes  prolonged  and  with  a  very 
obvious  effort.  A  hissing,  stridulous,  somewhat  snoring  noise  accom- 
panies the  inspiration,  but  expiration  is  easy  and  noiseless.  As  the 
inspiration  increases  in  difficulty,  all  of  the  muscles  needed  to  expand 
the  chest,  and  the  accessory  muscles  of  inspiration  also,  are  brought 
into  play.  The  inspiration  is  difficult,  because,  in  drawing  in  the  air, 
the  swollen  mucous  folds  are  brought  together  in  the  center,  and 
the  more  strongly  the  effort  is  made  the  more  tightly  the  folds  are 
approximated— for,  the  cartilages  of  the  larynx  keeping  the  lower 
cavity  open,  where  a  partial  vacuum  is  created  by  the  expansion  of  the 
chest,  the  incoming  air  pushes  the  mobile  folds  of  swollen  mucous 
membrane  before  it,  and  hence,  the  more  powerful  the  attempts  at 
inspiration,  the  more  tightly  the  folds  are  wedged  into  the  narrow 


428  DISEASES   OF   THE   RESPIRATORY   ORGANS. 

space.  Exph-ation  also  becomes  difficult  when  the  swollen  folds  be- 
come immovably  distended,  and  fixed  in  more  or  less  close  apposition. 
When  this  occurs,  expiration  becomes  stridulous,  whistling,  crowing, 
and  difficult,  but  not  usually  in  the  same  degree  as  inspiration. 

In  the  more  formidable  cases,  the  obstacles  to  the  entrance  of  air 
may  become  extreme  in  a  short  time,  the  patient  dying  asphyxiated. 
In  many  other  cases  the  group  of  symptoms  just  mentioned  are  varied 
by  attacks  of  suffocative  breathing  produced  by  spasm  of  the  muscles 
of  the  larynx.  Excited  by  cough,  by  attempts  at  swallowing,  or  the 
accumulation  of  secretion,  etc.,  on  a  sudden  the  breathing  is  arrested, 
the  face  gets  blue,  the  eyes  start  from  the  head,  there  are  wild  gasping, 
a  terrified  expression,  and  death  seems  imminent.  Death  may  occur 
in  such  an  attack.  Consciousness  may  be  lost,  and  then  the  breathing 
may  be  resumed  ;  again,  in  other  cases — but  usually  the  paroxysms  do 
not  proceed  so  far  as  unconsciousness — air  enters  the  lungs,  and  the 
ordinary  difficulty  of  breathing  goes  on  as  before.  The  existence  of 
the  obstruction  can  usually  be  made  out  by  carefully  passing  the  index- 
finger  over  the  base  of  the  tongue,  when  the  swollen  epiglottis  and 
aryteno-epiglottidean  folds  may  be  felt.  It  is  generally  impracticable 
to  use  the  laryngeal  mirror  when  the  case  is  well  advanced,  but,  earlier, 
valuable  information  may  be  gained  by  its  use. 

Course,  Duration,  and  Termination. — The  most  acute  cases  are  those 
occurring  during  the  course  of  some  infectious  malady,  as  typhoid. 
The  effusion  takes  place  in  a  few  hours,  and  the  patient  expires  in  a 
short  time,  asphyxiated.  Such  may  be  the  course  in  cases  of  scarlatina 
also.  In  the  more  chronic  kinds  of  laryngeal  disease,  if  oedema  occur, 
the  progress  of  obstruction  is  slower  ;  there  may  be  days  passed  be- 
tween the  first  attack  of  spasmodic  dyspnoea  and  the  fatal  result  from, 
the  asphyxia  of  oedema.  The  duration  of  infiltration  of  the  larynx 
varies  from  a  few  houi's  to  several  days. 

Diagnosis. — From  the  difficult  breathing  produced  by  capillary 
bronchitis,  emphysema,  and  asthma,  that  of  infiltration  of  the  larynx 
is  distinguished  by  the  important  characteristic  of  difficulty  in  inspi- 
ration, whereas  in  the  former  the  difficulty  is  iti  exjyiration.  The  aid 
afforded  by  digital  exploration  and  by  the  mirror,  when  practicable, 
will  enable  a  diagnosis  to  be  made  at  once.  Passing  the  index-finger 
carefully  over  the  base  of  the  tongue,  the  swollen  glosso-epiglottic 
folds,  etc.,  can  be  felt.  Croup,  or  laryngismus  stridulus,  foreign 
bodies,  polypi  of  the  larynx,  and  aneurisms  of  the  aorta  involving  the 
recurrent  laryngeal  nerve,  may  produce  symptoms  similar  to  oedema. 
The  attacks  of  pseudo-croup  come  on  suddenly,  occur  at  night,  are 
quickly  relieved,  and  between  the  paroxysms  there  is  no  trouble  of 
any  kind.  The  presence  of  foreign  bodies  and  polypi  is  determined 
by  the  use  of  the  laryngeal  mirror,  and  by  the  difference  in  the  rational 
symptoms.     The  history  of  the  case,  the  sudden  occurrence  of  suffo- 


LARYXGITIS.  429 

cative  attacks  after  the  accidental  inhalation  of  some  foreign  body, 
and  the  coming  on  or  cessation  of  difficult  breathing  according  to  the 
position  of  the  object,  are  characteristics  differing  from  those  due  to 
oedema.  The  symptoms  produced  by  laryngeal  polypus  are  of  slow 
development,  but  the  mirror  enables  a  view  to  be  had  of  the  growth, 
revealing  a  condition  of  the  larynx  very  different  from  that  of 
oedema. 

Treatment. — To  open  the  trachea  is  necessary  if  suffocation  is  im- 
minent, but,  before  resorting  to  such  a  severe  measure,  scarification  of 
the  swollen  membrane  should  be  practiced,  according  to  the  method  of 
Dr.  Gurdon  Buck,  of  New  York.  A  scalpel  wrapped,  but  leaving  the 
point  free,  is  passed  over  the  tongue,  guided  by  the  finger,  and  when 
the  swollen  parts  are  reached  the  cutting  edge  is  turned  against  them, 
and  free  scarifications  are  practiced.  If  pus  is  reached,  a  free  incision 
is  necessary  to  evacuate  it.  In  the  case  of  purulent  infiltration  the 
act  of  vomiting  may,  happily,  effect  a  rupture  of  the  depot.  Vomit- 
ing, for  this  purpose,  is  best  induced  by  the  hy^^o dermatic  injection 
of  apomorphia,  since  swallowing  becomes  so  difficult  in  these  cases. 
When  the  infiltration  is  serous,  absorption  may  be  effected  by  the  free 
salivary  and  cutaneoiis  discharge  induced  by  pilocarpus.  The  author 
has  had  no  experience  in  this  particular  use  of  the  agent,  but  he  ven- 
tures to  express  the  belief  that  great  relief  will  result  from  it.  It  is 
probable,  if  nothing  else  be  accomplished,  that  pilocarpus  will  relieve 
the  swelling  of  the  sublingual  and  cervical  glands.  As  the  effusion  is 
forming,  full  doses  of  quinia  should  be  given  before  the  pilocarpus,  and 
subsequently  to  support  the  vital  powers  reduced  by  the  loss  of  fluid. 
Quinia,  in  full  doses,  is  more  distinctly  serviceable  when  the  infiltrat- 
ing material  is  pus.  If  the  onset  of  the  disease  is  inflammatory,  and 
the  effusion  into  the  submucosa  is  the  result,  tincture  of  aconite-root 
should  be  freely  administered,  and  quinia  should  also  be  given  to  pre- 
vent migration  of  the  white  corpuscles.  As  this  disease  very  rapidly 
depresses  the  vital  powers,  it  is  important  to  supply  the  system  with 
nutritious  aliment  from  the  beginning.  The  careful  administration  of 
stimulants  is  also  necessary.  If  swallowing  becomes  very  difficult  and 
but  little  aliment  enters  the  stomach,  the  amount  taken  should  be  sup- 
plemented by  "rectal  alimentation."  Defibrinated  blood  should  be  in- 
jected into  the  rectum,  and  nutrient  enemata  should  also  be  employed. 


SPASM    OF    THE    GLOTTIS— PSEUDO-CROUP— liARYNGISMUS 

STRIDULUS. 

Definition. — Spasm  of  the  glottis  is  a  term  applied  to  spasm  of  the 
muscles  of  the  larynx,  innervated  by  the  recurrent  or  inferior  laryngeal 
nerves.  The  mechanism  consists  in  an  irritation  of  the  terminal  fila- 
ments of  the  pneumogastric,  in  the  mucous  membrane  of  the  larynx. 


430  DISEASES   OF   THE   RESPIRATORY   ORGANS. 

the  transmission  of  this  irritation  to  the  pneumogastric  nucleus,  and 
its  reflection  over  the  motor  nerves  supplying  the  laryngeal  muscles. 

Symptoms  and  Pathogeny. — Spasm  of  the  glottis  is  never  the  initial 
symptom.  For  the  first  day  or  two,  the  child  suffers  from  a  simple 
acute  catarrh.  There  may  be  slight  feverishness,  but  not  high  fever; 
there  is  more  or  less  nasal  catarrh  ;  the  eyes  are  apt  to  be  injected; 
the  throat  is  redder  than  normal ;  the  voice  is  a  little  hoarse,  and  there 
is  some  cough — in  fact,  the  symptoms  are  those  of  an  acute  cold. 
Toward  evening  the  voice  may  get  hoarser,  and  the  cough  assume  a 
more  ringing  tone.  But  in  the  night  the  child  awakes  rather  suddenly, 
coughing  in  the  brassy,  metallic,  resonant  tone  which  is  called  "  croupy." 
Every  strong  inspiration  is  accompanied  by  a  loud,  crowing  stridor, 
and  on  crying  each  inspiration  has  the  same  character,  the  expirations 
being  wheezy  and  somewhat  stridulous.  This  peculiarity  of  the  inspi- 
ration is  due  to  sudden  and  high  tension  of  the  vocal  cords,  they  being 
approximated,  and  consequently  narrowing  the  chink  through  which 
the  air  passes.  So  difficult  is  the  entrance  of  air,  that  the  accessory 
muscles  of  respiration  are  brought  into  use,  the  alse  of  the  nose  work 
convulsively,  the  face  and  lips  are  somewhat  bluish,  the  countenance  is 
anxious,  and  the  inferior  portion  of  the  chest  is  drawn  in  instead  of 
being  expanded  during  inspiration.  Such  is  an  ordinary  case  of  pseudo- 
croup.  Undoubtedly,  there  are  examples  of  the  disease  in  which  the 
point  of  irritation  is  the  stomach.  An  indigestible  supper,  or  some 
improper  article  eaten  during  the  evening,  may  set  up  an  irritation  of 
the  end-organs  of  the  pneumogastric,  which  may  be  reflected  over  the 
laryngeal  motor  nerves,  producing  the  symptoms  of  laryngismus  strid- 
ulus. In  which  mode  soever  produced,  spasm  of  the-  glottis  quickly 
subsides  under  appropriate  treatment,  and  in  an  hour  or  two  after  be- 
ing awakened  by  the  oppression  the  child  is  usually  sufficiently  relieved 
to  become  drowsy,  barking  in  its  sleep,  occasionally,  until  the  morning. 
This  experience  may  be  repeated  on  the  following  night,  and  indeed 
for  several  nights.  When  this  recurrence  of  the  paroxysms  takes 
place,  the  case  awakens  renewed  anxiety,  lest  an  exudation  may  be 
forming  in  the  larynx.  If  the  paroxysms  recur  for  two  nights,  there 
will  be  attacks  during  the  day  also.  The  author  has  observed  a  few 
cases  in  which  the  spasms  continued  for  several  days  ;  without  being 
violent  at  any  time,  the  cough  had  always  the  "  croupy  "  character, 
and  a  strong  inspiration  developed  stridor. 

Course,  Duration,  and  Termination. — The  simplest  cases  consist  of  a 
mild  acute  catarrh,  inducing  a  nocturnal  attack  of  spasm  of  the  glottis, 
which  terminates  in  an  hour  or  two.  The  catarrh  soon  subsides,  and 
there  is  no  return  of  the  spasm  of  the  glottis  until  succeeding  attacks 
of  catarrh  renew  the  disturbance  in  the  nervous  apparatus  of  the  larynx. 
As  only  certain  children,  though  by  no  means  a  small  proportion,  suffer, 
there  is  probably  a  peculiar  mobility  of  the  nervous  system  necessary. 


CROUP. 


431 


As  the  mobility  of  the  nervous  system  is  much  more  pronounced  in 
children  than  in  adults,  we  have  in  this  an  explanation  of  the  fact  that 
spasm  of  the  glottis  is  a  disease  of  early  life,  and  rarely  occurs  after 
twelve.  Although  a  malady  of  little  importance,  spasm  of  the  glottis 
accompanies  some  of  the  most  serious  diseases.  Thus  it  occurs  during 
the  course  of  true  croup,  diphtheria,  oedema  of  the  glottis,  etc.,  and  may 
be  the  immediate  cause  of  death  ;  and  in  all  cases  adds  materially  to 
the  difficulties,  by  the  frequent  spasms  in  the  laryngeal  muscles.  As 
it  usually  occurs  in  children,  arising  in  a  reflex  disturbance,  having  its 
origin  in  an  acute  catarrh,  or  an  acute  indigestion,  it  always  ends  in 
recovery.  There  are  occasional  (rather  rare)  cases  in  which  the  catarrh 
terminates  in  cedema  of  the  glottis. 

Diagnosis. — The  manner  of  its  occurrence  and  the  promptness  of 
the  cure  sufficiently  indicate  the  nature  of  pseudo-croup  without  the 
laryngeal  mirror. 

Treatment. — Formerly,  every  case  of  the  disease  was  subjected  to 
a  severe  ordeal,  and,  when  bloodletting  and  tartar  emetic  were  aban- 
doned, emesis  was  still  persevered  in.  Ko  perturbating  agents  of  this 
kind  are  really  necessary.  A  few  drops  of  the  fluid  extract  of  ipecac, 
given  every  twenty  minutes  until  nausea  is  produced,  will  relieve  if  a 
cold  wet  pack  about  the  neck  has  failed.  From  five  to  twenty  grains 
of  the  bromide  of  potassium  will  usually  succeed,  and  will  be  more  ef- 
fective if  some  chloral  is  added.  From  ten  minims  to  3  j  of  paregoric 
often  arrests  the  paroxysms.  A  minute  dose  of  pilocarpine  nitrate  or 
muriate  {j\  to  ^  grain)  will  stop  the  spasms  usually  when  diaphoresis 
begins.  As  it  is  so  mild  a  disease,  the  simplest  means  will  suffice  to 
cure  an  attack.  Children  accustomed  to  the  attacks  should  receive 
prophylactic  treatment.  A  daily  morning  cold  bath  to  diminish  the  sus- 
ceptibility to  colds,  the  sirup  of  the  iodide  of  iron,  or  the  lactophos- 
phate  of  lime,  to  promote  the  body  nutrition,  suitable  clothing,  and  out- 
door occupation,  are  the  most  approved  means  to  prevent  a  recurrence 
of  the  seizures. 

CROUPOUS  LARYNGITIS— TRUE  CROUP. 

Definition. — The  preponderance  of  authority  is  in  favor  of  that 
view  that  the  so-called  membranous  croup  is  only  laryngeal  diphtheria. 
The  author  is  one  of  those  who  maintain  that  croiq)Ous  laryngitis,  or 
membranous  croup,  is  an  independent,  substantive  disease  ;  that  we 
have  a  croupous  laryngitis  as  we  have  a  croupous  bronchitis  and  a 
croupous  enteritis.  The  author  believes  that  this  disease  is  distinct 
and  separate  from  diphtheria,  for  the  following  reasons  :  it  occupies 
the  larynx  exclusively,  is  a  purely  local  affection,  the  exudation  is  on 
and  not  in  the  mucous  membrane,  and  that  systemic  poisoning,  or  sec- 
ondary septicsemic  and  infective  embolic  processes  never  result  from  it. 

Causes. — Croup  is  a  disease  of  childhood,  and  very  rarely  occurs 


432  DISEASES   OF   THE   RESPIRATORY   ORGANS. 

later  than  the  second  dentition,  and  attacks  male  children  by  prefer- 
ence, in  the  proportion  of  three  to  two.  It  is  not  merely  the  ill-fed 
children  of  the  poor,  or  the  inheritors  of  scrofula  and  rickets,  who  are 
chiefly  attacked,  but  the  vigorous  and  well-nourished  are  more  liable. 
It  is  certain  that  heredity  has  an  important  influence  in  its  causation, 
in  that  certain  families  are  especially  liable  to  destructive  visitations, 
and  others,  living  under  similar  conditions,  escape.  Notwithstanding 
the  prevalent  opinion  that  humidity,  coldness,  and  variability  of  cli- 
mate favor  the  development  and  spread  of  croup,  we  find  that  Lombard 
says  "  he  has  sought  in  vain  to  discover  any  difference  in  the  develop- 
ment of  this  disease  as  regards  climate,  latitude,  and  altitude."*  It 
seems,  nevertheless,  well  established,  that  humidity  favors  its  occur- 
rence, and  that  more  cases  occur  in  winter  and  spring  than  in  summer. 
That  true  croup  prevails  as  an  epidemic  is  highly  improbable,  but,  as 
diphtheria  does,  the  error,  if  it  exist,  has  arisen  by  confounding  the 
diseases,  A  croupous  laryngitis  sometimes  arises  during  the  course  of 
the  acute  infectious  diseases,  as  measles,  scarlatina,  small-pox,  etc.,  but 
of  measles  especially.  This  may  be  a  diphtheritic  process  superadded 
to  an  existing  lesion,  but  is  more  probably  a  mere  croupous  inflamma- 
tion. 

Pathological  Anatomy. — The  initial  hypersemia  is  of  an  intense 
character  ;  the  mucous  membrane  is  swollen,  has  a  deep-red  color,  is 
marked  by  an  exceedingly  fine  but  diffused  arborescent  injection,  and 
here  and  there  by  minute  ecchymoses,  and  the  sub-mucous  connective 
tissue  is  more  or  less  (Edematous.  In  the  progress  of  the  case  the  red- 
ness subsides  to  a  large  extent,  but  the  membrane  continues  somewhat 
thickened  for  some  time  longer.  Soon  after  the  hyperaemia  attains  its 
maximum,  there  appears  on  the  surface  of  the  inflamed  mucous  mem- 
brane a  grayish,  semi-transparent  pellicle,  which  soon  becomes  thicker, 
grayish-white,  yellowish,  or  brownish — an  opaque  false  membrane.  At 
various  places  the  false  membrane  differs  in  coherence,  density,  and 
adhesiveness  :  here,  several  lines  in  thickness,  uniform  in  structure,  and 
firmly  attached  to  the  mucosa  ;  there,  in  flakes  or  patches,  loosely  at- 
tached to  the  surface  beneath.  The  false  membrame  is  found  on  the 
vocal  cords  throughout  their  whole  extent  usually,  spread  over  the  ven- 
ti'icles,  and  attached  to  the  inner  surface  of  the  epiglottis.  There  may 
be  none  found  i^ost  mortem,  it  is  alleged  ;  but  probably  in  these  ex- 
amples there  was  an  error  of  diagnosis.  Successive  deposits — two  or 
three — may  occur  ;  the  first  exuded  is  softened  by  the  serum  which 
transudes,  as  does  the  albumen,  and  is  mechanically  detached  in  the  act 
of  coughing.  As  expectorated  it  usually  appears  in  the  form  of  grayish- 
white  shreds  or  casts,  several  lines  in  thickness,  and  tolerably  tough. 
Sometimes  a  cast  of  the  trachea  and  tubes  of  considerable  extent  is 

*  "Traite  de  Climatologie  Medicale,"  etc.,  tome  iv,  Paris,  1880,  p.  401. 


CROUP.  433 

tlirowTi  off,  but  this  is  exceptional.  On  microscopic  examination,  the 
false  membrane  is  found  to  be  composed  of  a  fine  network  of  fibrillae, 
holding  in  their  interstices  leucocytes,  and  chemically  of  an  albumi- 
nous nature,  or  of  fibrin.  Soon  after  the  false  membrane  fonns  on  the 
epithelial  surface  of  the  mucosa,  a  process  of  detachment  begins,  bv 
the  accumulation  of  serum,  having  suspended  in  it  muco-pus,  cast-off 
epithelial  cells,  blood-corpuscles,  etc.  The  mucous  membrane,  when  the 
exudation  is  detached,  is  found  to  be  unaffected,  except  the  hypersemia, 
and  the  imbibition  of  fluid  affecting  the  epithelial  cells.  In  this  ab- 
sence of  direct  implication  of  the  epithelium  lies  the  distinction  be- 
tween croup  and  diphtheria,  for  in  the  latter  the  false  membrane  is 
closely  united  to,  and  is  probably  developed  from,  the  cells  of  the  epi- 
thelium, as  E.  Wagner  has  apparently  shown.  After  the  exfoliation 
of  the  first  croupous  exudation,  there  may  be  several  successive  crops 
of  exudation,  or,  ceasing  to  form  again,  a  cure  is  effected.  The  false 
membrane  is  not  confined  to  the  parts  on  which  it  first  appears,  but 
extends  upward  into  the  pharynx,  but  especially  downward  into  the 
trachea,  primary  bronchi,  and  smaller  bronchi.  As  the  membrane  ex- 
tends toward  the  finer  tubes,  it  becomes  less  fibrillary  and  more  cellular, 
until  at  length  it  is  a  mere  muco-purulent  fluid.  The  lungs  are  affected 
by  emphysema,  and  here  and  there  atelectasis,  the  result  of  the  inspir- 
atory obstruction  and  the  tenacity  of  the  exudation  blocking  some  of 
the  finer  tubes. 

Symptoms. — The  attack  of  croup  usually  but  not  invariably  begins 
as  an  acute  catarrh  of  the  larynx  ;  there  is  a  feeling  of  heat  and  in-ita- 
tion  in  the  organ,  and  the  voice  is  a  little  husky  ;  there  is  cough  with 
something  of  stridor  about  it,  and  fever,  restlessness,  thirst,  anorexia, 
and  distui'bed  sleep,  accompany  the  evidences  of  laryngeal  mischief. 
When  the  fauces  are  inspected,  more  or  less  redness,  sometimes  duskv 
redness,  will  be  observed,  and  also  small  patches  of  a  thin,  pellicular 
exudation  of  a  grayish-yellow  color,  studded  over  the  j)alate,  tonsils, 
and  pharynx.  These  patches  presently  coalesce  and  then  form  a 
denser  membrane  several  lines  in  thickness,  of  a  yellowish-gray  or  ash 
color.  As  huskiness  of  voice  was  one  of  the  initial  symptoms,  the 
same  patches  of  pellicular  exudation  are  forming  in  the  larynx.  Al- 
though it  is  affirmed  of  croup  that  the  exudation  spreads  sometimes 
over  the  tongue,  cheeks,  lips,  into  the  nose,  ears,  etc.,  these  cases  so 
behaving  are  examples  of  diphtheria,  it  is  most  probable,  for  true  croup 
does  not  extend  beyond  the  pharynx  and  soft  palate.  The  submaxil- 
lary glands  become  somewhat  tumid  and  swollen,  but  not  the  chain 
of  cervical  glands  extending  under  the  stemo-cleido-mastoid  muscles, 
which  are  enlarged  in  diphtheria.  Usually  from  one  to  two  days  are 
occupied  with  the  development  of  the  catarrhal  foi'm,  but  other  and 
rare  cases  commence  with  abruptness  in  the  night,  as  an  ordinary 
spasm  of  the  glottis.  In  what  mode  soever  developed,  there  now 
28 


434  DISEASES   OF   THE   RESPIRATORY   ORGANS. 

appear  the  symptoms  of  laryngeal  obstruction.  The  hoarseness  has 
become  fixed,  and  the  cough  assumes  a  clanging,  metallic,  or  "croupy  " 
character,  rapidly  changing  to  a  stridulous,  husky,  and  toneless  sound. 
Now  and  then,  on  sudden,  deep  inspiration,  there  is  still  the  peculiar 
whoop,  but  the  voice  becomes  more  and  more  husky.  Dyspnoea  now 
comes  on.  The  respii'ations  increase  in  fi-equency,  and  are  seen  to 
be  so  labored  as  to  require  the  aid  of  all  the  muscles.  The  child 
can  not  lie  down.  If,  exhausted  by  the  efforts  made,  the  child  seeks 
repose,  resting  its  head  high  upon  a  pillow,  it  soon  starts  up  in  a 
fright,  breathing  more  heavily,  and  with  a  shrill,  whistling  inspira 
tion.  Tossing  from  side  to  side,  he  seeks,  in  endless  changes  of  po- 
sition, for  the  relief  which  no  change  brings.  With  open  mouth, 
rapidly  working  alse  of  the  nose,  and  every  respiratory  muscle  called 
into  play,  he  exerts  himself  to  the  utmost  to  obtain  the  necessary  air, 
but  ineffectually,  the  lower  portion  of  the  chest  being  drawn  in  deej^ly 
with  each  inspiration.  The  air  passes  with  difficulty  through  the  nar- 
rowed chink  of  the  glottis,  and  hence  the  slowness,  and  the  whistling, 
crowing,  and  stridulous  inspirations,  which  can  be  heard  at  quite  a 
distance  from  the  patient.  Ultimately  the  narrowing  of  the  glottis  is 
such  that  expiration  becomes  difficult  and  somewhat  noisy.  To  the 
difficulty  of  breathing  from  the  swelling  of  the  mucosa  and  the  pres- 
ence of  the  false  membrane  are  now  added  paroxysmal  attacks  of  spasm 
of  the  glottis.  When  these  attacks  come  on,  suffocation  seems  immi- 
nent. The  child,  who  has  been  restless  when  these  seizures  are  felt, 
tosses  wildly  about  with  an  agonized  expression,  tears  at  his  throat  to 
remove  some  obstacle,  the  face  cyanosed,  the  alse  of  the  nose  widely 
separated,  the  inspiratory  efforts  gasping,  and  the  muscles  working  to 
their  utmost,  the  body  covered  with  a  profuse  sweat  from  the  inten- 
sity of  the  exertions  ;  and  at  last,  when  death  seems  at  hand,  a  little  air 
enters  the  chest,  the  breathing  becomes  somewhat  easier,  and  the  child, 
exhausted  and  stupefied  by  the  carbonic  acid  which  is  accumulating, 
drops  into  a  fitful  sleep  of  a  few  minutes'  duration.  These  suffocative 
attacks  appear  at  shorter  intervals.  By  some  these  attacks  are  sup- 
posed to  be  due  to  a  paresis  of  the  laryngeal  muscles  instead  of  spasm, 
and  Steiner  supports  the  opinions  of  Niemeyer  on  this  point.  In  some 
cases  there  occur  decided  remissions  between  the  attacks  of  suffocative 
dyspnoea.  Considerable  portions  of  false  membrane  being  expelled, 
air  again  enters  the  lungs  ;  the  cyanosis  disappears,  the  fever  ceases, 
and  some  refreshing  sleep  is  obtained.  As  the  false  membrane  is 
renewed  again,  the  foi-mer  difficulties  are  resumed  ;  the  breathing  be- 
comes difficult,  and  the  suffocative  attacks  even  more  violent.  Some- 
times a  mass  of  exudation  is  suddenly  detached  and  thrown  against 
the  under  surface  of  the  vocal  cords  ;  breathing  is  suspended,  the  child 
turns  deeply  blue  in  the  face,  and  violent  coughing  sets  in,  detaching 
the  mass,  and  either  carrying  it  down  by  inspiration,  or  outward  by  an 


CROUP.  435 

explosive  cough.  In  the  cases  which  tend  to  a  favorable  termination, 
the  appearances  of  improvement,  noted  between  the  suffocative  at- 
tacks, are  maintained.  The  paroxysms  of  suffocation  become  less 
frequent,  and  the  constant  dyspnoea  visibly  lessens  ;  the  cough  has  less 
and  less  of  the  barking  character,  and  the  expectoration  is  more  abun- 
dant and  looser  ;  the  fever  disappears  ;  the  voice  gradually  passes  from 
toneless  to  husky  and  loud  ;  sneezing  occurs,  and  the  nose  discharges. 
If,  instead  of  improvement,  the  case  goes  on  as  usual  to  a  fatal  ter- 
mination, the  final  stage  of  asphyxia,  or  carbonic-acid  poisoning,  is 
now  entered  on.  The  cyanosis  deepens,  the  agonized  expression  of 
countenance  is  replaced  by  indifference,  drowsiness,  and  stupor,  the 
eye  grows  dull  and  is  nearly  closed,  the  difficulty  of  breathing  con- 
tinues, and  the  respirations  are  frequent  and  shallow,  but  without  the 
whistling  and  stridor.  Now  and  then  a  paroxysm  of  dyspnoea  comes 
on,  in  which  the  child  is  roused  from  its  somnolent  condition,  gasps 
for  breath,  struggles,  and  then  lies  down,  passing  at  once  into  an 
apathetic  state.  The  symptoms  of  vital  failure  now  come  on  :  the 
pulse  becomes  rapid  and  weak  ;  a  cold,  clammy  sweat  covers  the 
body  ;  the  extremities  are  cold,  the  somnolence  deepens  into  stupor 
and  insensibility,  carpopedal  contractions  occur,  and  sometimes  gen- 
eral convulsions. 

Course,  Duration,  and  Termination. — The  first  stage,  characterized 
by  the  symptoms  of  laryngeal  catarrh,  runs  its  course  in  twenty -four 
to  thirty-six  hours.  The  fulminant  cases,  beginning  abruptly  at  the 
second  stage,  with  its  symptoms  of  laryngeal  stenosis,  will  terminate 
fatally  within  two  days,  and  sometimes  within  one  day.  The  usual 
duration  of  ordinary  cases  is  about  one  week,  and  rarely  do  cases  ex- 
tend to  ten  days.  The  second  stage  may  continue  from  one  to  four- 
teen days,  but  the  latter  duration  must  be  regarded  as  exceptional. 
The  third — the  stage  of  asphyxia — lasts  from  thirty-six  to  forty-eight 
hours.  In  most  of  the  cases  the  cause  of  death  is  general  paralysis, 
due  to  carbonic-acid  poisoning.  Very  rarely  is  death  caused  by  ap- 
noea,  the  access  of  air  prevented  by  closure  of  the  glottis  with  shreds 
of  false  membrane,  or  by  spasm.  (Edema  of  the  glottis,  croupous 
pneumonia,  oedema  of  the  lungs,  or  capillary  bronchitis,  may  be  a 
cause  of  death. 

Diagnosis. — Until  the  characteristic  membranous  formation  appears 
in  the  throat,  croupous  laryngitis  may  be  confounded  with  pseudo- 
croup  or  laryngismus  stridulus.  The  latter  occurs  frequently  in  some 
children,  comes  on  suddenly  in  the  night,  and  after  a  few  hours  ceases 
to  give  trouble.  True  croup  develops  more  slowly  and  does  not  pre- 
sent the  apparent  laryngeal  obstruction  of  false  croup  until  the  case  is 
well  advanced.  The  fulminant  form,  it  is  true,  begins  abruptly  and 
with  violence,  but  there  is  no  amelioration  in  the  condition  as  in  pseudo- 
croup.     The  most  certain  means  of  diagnosis  consists  in  the  discovery 


436  DISEASES   OF   THE   RESPIRATORY   ORGANS. 

of  the  exudation,  wliich  soon  appears  after  the  initial  symptoms  are 
well  declared. 

Treatment. — The  means  employed  in  the  treatment  of  membran- 
ous laryngitis  are  naturally  divisible  into  two  classes — local,  systemic. 
An  almost  infinite  variety  of  remedies  have  been  applied  to  the  throat : 
we  mention  those  that  are  really  useful.  Caustic  applications,  as  ni- 
trate of  silver,  the  mineral  acids,  etc.,  are  injurious  ;  for,  although  they 
may  remove  the  existing  membrane,  they  can  not  prevent  its  reforma- 
tion, and  the  extension  of  the  exudation  is  invited  to  the  healthy  tissue 
corroded  by  the  caustic.  Solvents  that  are  not  irritating  are  most  use- 
ful. The  first  and  most  important  one  is  lime-water,  which  may  be 
applied  by  a  large  soft  probang,  or  atomized  by  a  spray  douche.  The 
application  of  the  spray  should  be  nearly  continuous  ;  of  the  probang, 
frequent.  An  excellent  method  consists  in  slaking  bits  of  freshly 
burned  lime  in  water  placed  in  a  wide-mouthed  bottle — the  patient 
inhaling  the  vapor  as  it  arises.  Next  to  lime-water  is  lactic  acid,  as  a 
solvent,  and  it  is  as  safe  as  it  is  efficient.  Sufficient  of  the  acid  should 
be  added  to  water  until  a  distinctly  sour  solution  is  obtained,  and  this 
may  be  freely  applied  by  the  spray  douche  or  probang.  Recent  re- 
ports are  very  favorable  to  washed  sulphur  or  sublimed  sulphur  freely 
dusted  over  the  affected  j)arts  in  diphtheria.  Chlorate  of  potassa  is 
preferred  by  many,  either  atomized  or  on  probang  or  brush  ;  it  is  also 
used  with  chloride-of-iron  tincture,  or  the  latter,  undiluted,  is  applied 
on  a  camel's-hair  brush  to  the  false  membrane  and  fauces.  The  bro- 
mides of  potassium  and  ammonium,  in  solution,  are  also  sprayed  over 
the  throat  and  fauces.  Good  results  have  been  claimed  for  a  mixture 
of  fluid  extract  of  belladonna  and  the  bromides  in  solution,  used  in  the 
same  way,  a  continuous  application  of  the  spray  for  hours  at  a  time, 
or  until  the  pupils  are  affected.  It  is  claimed  for  this  mixture  that  the 
belladonna  allays  the  spasms  of  the  glottis.  A  solution  of  chloral  has 
been  employed  as  a  local  application,  both  for  its  antiseptic  effects  and 
as  a  moderator  of  the  reflex  spasms  of  the  laryngeal  muscles.  The  inter- 
nal remedies  are  equally  numerous.  There  are  three  main  objects  to  be 
kept  in  view  in  the  treatment  of  true  croup  :  to  detach,  remove,  and 
prevent  the  formation  of  the  false  membrane  ;  to  prevent  the  attacks  of 
laryngeal  spasms  ;  to  maintain  the  strength.  Quinia,  calomel,  chlorate 
of  potassa,  tincture  of  iron,  and  the  bromides,  are  recommended,  and 
some  of  them  much  lauded  by  their  respective  proposers.  There  are 
two  of  unquestionable  utility — quinia  and  bromide  of  ammonium. 
Quinia  should  be  administered  in  full  doses  ;  for  a  child  (three  to  five 
grains'  every  three  or  four  hours)  cinchonism  should  be  kept  up  as 
fully  as  possible,  with  the  object  to  stop  the  fibrinous  exudation.  In 
alternation  with  quinia,  or  by  itself,  should  be  administered  full  doses 
of  bromide  of  ammonium.  The  particular  fact  which  gives  value  to 
this  and  the  other  bromides  is  its  elimination  by  the  bronchial  and 


CORYZA.  437 

faucial  mucous  membrane,  thus  acting  locally.  Furthermore,  quinia 
and  the  bromides  check  the  spasm  of  the  laryngeal  muscles,  a  most 
important  action.  The  mechanical  effect  of  an  active  emetic  is  often 
necessary  to  dislodge  the  obstructing  membrane.  Apomorphia  is  es- 
pecially effective  for  this  purpose.  Ipecac  is  too  depressing,  tartar 
emetic  is  highly  objectionable,  alum  and  subsulphate  of  mercury  are 
the  best.  According  to  Barker,  of  New  York,  the  subsulphate  has 
special  po"\ver  as  a  remedy  for  croup,  an  opinion  in  which  the  author 
is  disposed  to  share.  It  should  be  given  early,  and  not  wait  for  severe 
obstruction.  Besides  the  agents  above  advised — quinia  and  the  bro- 
mides— for  the  laryngeal  spasms  chloral  is  to  be  commended.  The 
author  has  preferred  to  give  chloral  and  bromide  of  ammonium  to- 
gether, and  the  quinia  separately.  Besides  its  power  to  allay  the 
spasms,  chloral  is  one  of  the  few  remedies  which  possess  the  property 
to  check  the  formation  of  an  exudation.  Many  practitioners  hold  that 
chlorate  of  potassa  has  this  property  (Steiner),  and  this  remedy  is 
probably  more  largely  prescribed  than  any  other  in  croup  and  diph- 
theria. There  are  practitioners  who  still  hold  to  the  aplastic  virtues 
of  calomel,  and  use  this  remedy  in  large  doses,  with  asserted  success, 
but  the  most  approved  authorities  are  opposed  to  both  opinion  and 
practice  (Oppolzer,  Steiner).  The  measures  to  maintain  the  strength 
are  very  important.  Alcoholic  stimulants  possess,  according  to  the 
Brooklyn  physicians,  some  peculiar,  possibly  specific  curative  power. 
It  is  alleged  that  the  best  results  are  obtained  in  diphtheria  by  large 
and  sustained  administration  of  whisky,  brandy,  etc.  How  far  these 
facts  are  applicable  to  true  croup  remains  to  be  seen. 


CORYZA— NASAL  CATARRH. 

Definition. — By  the  term  coryza  is  meant  a  catarrhal  inflammation 
of  the  nasal  mucous  membrane.     It  may  be  either  acute  or  chronic. 

Causes. — Atmospherical  causes  are  the  most  frequent  and  influen- 
tial. The  exposure  of  the  neck  to  a  current  of  cold  air,  of  the  feet 
and  ankles  to  cold  and  dampness,  passing  from  a  warm  to  a  cold  at- 
mosphere, and  from  a  cold  to  a  warm  atmosphere  suddenly,  are  among 
the  most  usual  causes.  Irritating  gases  and  vapors,  the  spores  of  some 
plants,  certain  powders,  as  ipecac,  tobacco,  etc.,  excite  an  irritation  of 
the  nasal  mucous  membrane.  Heredity  is  an  occasional  factor.  Epi- 
demic influence  now  and  then  prevails  on  an  extensive  scale. 

Pathological  Anatomy. — An  intense  hyperemia  is  the  first  change, 
with  an  arrest  of  secretion.  This  is  soon  followed  by  swelling  or 
tumefaction  of  the  membrane  ;  the  epithelium  is  detached,  and  a  great 
number  of  new  cells  are  produced.  The  mucous  glands  furnish  an 
abundant  secretion  very  rich  in  saline  constituents.  If  the  congestion 
is  intense,  vessels  are  ruptured,   and  more  or  less  epistaxis  results 


438  DISEASES   OF   THE   RESPIRATORY   ORGANS. 

With  the  progress  of  the  case,  a  change  occurs  in  the  character  of  the 
discharge  ;  at  first  watery  and  transparent,  it  becomes  thicker  and 
opaque  with  the  increase  of  the  pus-cells  (leucocytes).  When  recovery 
takes  place,  the  secretion  diminishes,  the  congestion  subsides,  and  the 
swelling  of  the  membrane  disappears.  Such  is  the  usual  course  of  an 
acute  inflammation.  In  the  chronic  form,  the  mucous  membrane  is 
reddish-brown,  in  veiy  old  cases  grayish,  the  veins  are  dilated  and 
varicose,  often  forming  polypoid  protrusions.  There  may  be  more  or 
less  extensive  ulceration,  and  losses  of  substance,  in  old  cases.  The 
discharge  is  thick,  greenish ,  and  often  offensive  from  decomposition. 
Large  collections  of  inspissated  mucus  form  on  the  turbinated  bones. 

Symptoms. — Taking  cold  in  the  head  is  announced  by  chilliness, 
weariness,  headache,  and  general  muscular  soreness.  The  nares  are 
dry,  feel  stuffed  and  uncomfortable,  and  an  inclination  to  sneeze  is 
often  felt.  Presently  the  nose  pours  out  an  abundant  watery  and 
saline  discharge,  the  anterior  nares  are  red  and  inflamed,  and  sneez- 
ing is  frequent.  The  discharge  soon  assumes  a  purulent  character, 
and  contains  numerous  micrococci.  The  voice  has  a  peculiar  tone, 
rather  nasal  and  mufiled  from  the  swelling  of  the  nasal  mucous  mem- 
brane. In  a  few  days  the  swelling  subsides,  the  secretion  lessens,  and 
health  is  restored  in  about  two  weeks  from  the  beginning  of  the  attack. 
The  chronic  form  may  grow  immediately  out  of  the  acute  affection,  or 
it  may  be  the  result  of  repeated  acute  attacks,  or  develop  from  the  con- 
tinued operation  of  the  causes.  In  the  chronic  form  of  the  disease,  the 
mucous  membrane  is  either  livid,  the  vessels  varicose,  and  the  connec- 
tive-tissue basis  of  the  mucous  membrane  hypertrophied,  or  the  mem- 
brane is  pale,  thin,  bloodless,  and  atrophied.  The  discharge  consists 
of  greenish,  offensive  pus,  or  of  scales  taking  the  form  of  casts  of  the 
bones,  which  are  also  offensive  fi'om  decomposition.  If  the  mucous 
membrane  is  destroyed  by  ulcerations,  and  caries  of  the  bones  has 
occurred,  the  case  is  then  called  ozmna.  The  morbid  process  extends 
through  the  nasal  passages  and  into  neighboring  cavities. 

Course,  Duration,  and  Termination. — The  acute  form  reaches  its 
maximum  in  a  few  days,  and  terminates  in  from  fourteen  to  sixteen 
days  if  uninterfered  with.  The  chronic  form  is  excessively  obstinate, 
and  continues  with  varying  fortunes  for  several  years.  During  the 
summer  and  autumn  it  is  milder,  but  in  the  winter  and  spring  it 
is  worse.  Although  there  is  no  danger  to  life,  the  disease  in  its  chronic 
form  is  difficult  to  cure.  The  popular  notion  that  extension  to  the 
lungs  takes  place  is  entirely  unfounded.  In  the  phthisical,  the  coex- 
istence of -nasal  catarrh  and  the  pulmonary  lesions,  which  is  very  com- 
mon, is  often  supposed  to  mean  the  dependence  of  the  latter  on  the 
former. 

Treatment. — An  existing  constitutional  dyscrasia,  especially  syphi- 
lis, needs  attention.      If  the  least  suspicion  may  be  entertained,  an 


EPISTAXUS.  439 

iodide-of-potassium  course  should  be  carried  out.  When  there  is  a 
strumous  diathesis,  cod-liver  oil,  the  phosphates,  iodide  of  iron,  etc., 
should  be  employed.  If  we  have  to  deal  with  an  attack  of  acute  ca- 
tarrh, an  attempt  may  be  made,  and  will  often  prove  successful,  to 
abort  it  by  the  administration  of  a  full  dose  of  quinia  and  morphia  (for 
an  adult,  gr.  xv  of  quinia  and  gr.  ss.  of  morphia).  When  established, 
the  best  remedy  is  Lugol's  solution,  one  drop  every  hour  or  two.  If 
there  is  fever,  one  drop  of  tincture  of  aconite-root  every  hour  will  prove 
efficient.  If  the  secretion  is  watery  and  profuse,  tincture  of  belladon- 
na may  be  given  with  the  aconite,  two  drops  every  two  hours.  In  the 
local  treatment  of  chronic  catarrh,  the  first  step  necessary  is  to  clear 
the  mucous  surface  of  adherent  discharges.  The  nasal  douche,  so  much 
employed,  has  so  often  given  rise  to  inflammation  of  the  middle  ear, 
by  forcing  the  application  into  the  Eustachian  tube,  that  it  must  be 
used  with  caution.  The  post-nasal  syringe  and  tepid  water  containing 
a  little  common  salt  are  the  best  materials  for  cleansing  the  passage. 
Numerous  are  the  kinds  and  forms  of  applications — gaseous,  liquid, 
and  solid.  The  volatile  applications  consist  chiefly  of  iodine  and  car- 
bolic acid,  separately  or  in  combination.  The  tincture  of  iodine  and 
carbolic  acid  may  readily  be  volatilized  and  inhaled  from  a  small  bot- 
tle. The  liquid  applications  consist  of  solutions  of  chlorate  of  potassa, 
chloride  of  ammonium,  sulphates  of  zinc,  cadmium,  and  copper,  acetate 
of  lead,  etc.  The  solutions  must  be  very  dilute,  not  stronger  than  one 
grain  of  sulphate  of  zinc  to  four  ounces  of  water,  for  example,  because 
of  the  very  sensitive  condition  of  these  parts.  When  there  are  great 
thickening  and  ulceration,  i-equiring  strong  applications,  they  must  be 
made  with  the  guidance  of  the  mirror,  and  be  confined  to  the  part 
diseased.  The  most  effective  application,  according  to  the  author's 
experience,  is  a  powder  composed  of  tannin  and  iodoform  (  3  j — gv. 
x)  applied  by  means  of  an  insufflator.  The  membrane  must  be  first 
cleansed,  then  the  powder  is  dusted  over  the  diseased  part,  using  a 
very  small  quantity.  Pressure  by  means  of  a  graduated  series  of 
bougies  is  a  valuable  mode  of  treating  those  cases  in  which  the  mem- 
brane is  much  thickened. 


EPISTAXIS— NASAL  HJEMORRHAGE. 

Causes. — The  Schneiderian  mucous  membrane  is  abundantly  sup- 
plied with  blood-vessels  and  bleeds  easily.  JEpistaxis  may  be  caused 
by  ulceration  of  the  membrane,  by  vascular  tumors,  by  traumatism, 
by  a  constitutional  state — the  hremorrhagic  diathesis — by  irritation  of 
the  mucous  membrane,  and  by  mechanical  causes,  as  valvular  disease 
of  the  heart,  and  the  pressure  of  an  intra-cranial  growth,  etc. 

Sjnnptoms. — There  may  be  a  sense  of  fullness  of  the  head,  head- 
ache, noises  in  the  ears,  vertigo,  precede  the  epistaxis,  and  be  relieved 


44-0  DISEASES   OF   THE   RESPIRATORY   ORGANS. 

by  it,  or  the  bleeding  may  occur  without  any  previous  symptom  to 
indicate  its  approach.  The  blood  may  at  first  be  observed  on  the 
handkerchief  ;  a  sense  of  moisture  about  the  nares  suggests  the  neces- 
sity of  blowing  the  nose,  and  then  blood  is  seen  coming  drop  by  drop, 
and  from  a  single  nostril.  The  blood  may  be  discharged  by  the  pos- 
terior nares  and  be  expectorated.  On  inspection  of  the  fauces,  it  will 
be  seen  trickling  down  the  soft  palate  and  uvula,  which  will  prevent 
the  mistake  of  supposing  it  comes  from  the  lungs.  The  quantity  of 
blood  discharged  varies  greatly.  In  most  cases  an  ounce  or  two  is  lost, 
when  the  flow  spontaneously  ceases  ;  again,  many  ounces — a  pint,  a 
quart  even — may  be  lost,  completely  blanching  the  patient,  and  only 
ceasing  because  of  the  faintness.  If  the  bleeding  occur  in  a  subject 
of  the  hsemorrhagic  diathesis,  it  may  continue  to  faintness  and  be  re- 
sumed again  as  soon  as  the  circulation  regains  its  force.  Under  these 
circumstances  epistaxis  may  endanger  life.  Again,  epistaxis  may  occur 
periodically,  as  a  manifestation  of  malaria,  or  take  the  place,  vicariously, 
of  the  menstrual  or  hajmorrhoidal  flux.  Those  cases  due  to  the  pres- 
sure of  a  tumor  on  the  cavernous  sinus,  or  pterygoid  plexus,  are  ac- 
companied by  swelling  of  the  eyelids,  injections  of  the  eyes,  retinal 
changes,  and  the  symptoms  proper  to  tumor  of  the  brain. 

Diagnosis. — There  can  be  no  difiiculty,  if  the  inspection  is  made 
when  the  blood  is  flowing,  in  determining  the  source  of  the  haemor- 
rhage. When,  however,  the  bleeding  occurs  in  sleep,  from  the  poste- 
rior nares,  and  is  swallowed,  there  may  be,  if  vomiting  of  the  blood 
occurs,  much  difficulty  in  ascertaining  the  true  source.  But  the  absence 
of  any  evidence  of  stomach  ulcer  and  the  occasional  occurrence  of  nose- 
bleed will  suggest  the  means  of  differentiation.  The  same  method  of 
analysis  will  be  equally  applicable  to  the  apparent  expectoration  of 
blood,  for  the  absence  of  pulmonary  disease  and  the  occasional  occur- 
rence of  epistaxis  will  decide  the  probability  in  favor  of  bleeding  at 
the  nose. 

Treatment. — The  application  of  cold,  in  the  form  of  ice,  small 
pellets  of  which  may  be  introduced  into  the  nares,  while  a  block  of  ice 
hollowed  out  to  fit  the  nose  may  be  put  on  outside,  will  often  be  suf- 
ficient to  arrest  the  bleeding.  Pressure  on  the  artery  supplying  the 
anterior  nares  may  be  easily  effected  by  passing  the  little  finger  under 
the  lip,  near  the  middle  line  where  the  artery  may  be  felt.  Simply 
pressing  the  nares  together,  to  enable  the  blood  to  coagulate,  may  often 
suffice.  If  pressure  and  cold  fail,  a  solution  of  tannic  acid,  or  of  alum, 
or  of  acetate  of  lead,  may  be  thrown  into  the  nares,  and,  if  these  fail,  a 
solution  of  Monsel's  salts.  The  measures  above  advised  may  be  sup- 
plemented by  the  hypodermatic  injection  of  ergotin,  if  necessary,  and 
by  the  stomachal  administration  of  arterial  sedatives,  as  veratruni  viride 
and  digitalis.  All  other  expedients  failing,  the  posterior  nares  must 
be  plugged. 


COXGESTIOX  or   THE   KIDNEY.  4^^^ 


DISEASES   OF   THE  KIDNEY. 


CONGESTION   OF   THE   KIDNEYS— ACTIVE. 

Definition.  —  Hypera8mia  of  the  kidneys  signifies  an  increased 
amount  of  blood  in  tiie  organs.  The  hypersemia  may  be  in  the  arte- 
rial supply — active  congestion,  or  in  the  venous  supply — -^:/ass^ye  con- 
gestion. 

Causes. — Active  congestion  is  usually  caused  by  some  irritating 
substance  which  is  eliminated  by  the  urine.  Yarious  medicinal  agents, 
containing  an  essential  oil,  or  a  camphor,  as  copaiba,  cubebs,  eucalyp- 
tol,  etc.,  excite  ii-ritation  in  the  kidneys,  as  these  substances  pass  through 
in  the  process  of  elimination.  Turpentine  and  cantharides  are  among 
the  most  active  of  these  agents,  and  more  frequently  cause  acute 
congestion  than  any  other.  A  mustard-plaster  may  also  cause  the 
same  result,  due  doubtless  to  the  absorption  and  elimination  of  the  oil 
of  mustard.  An  extensive  bum,  a  counter-irritant  affecting  a  consid- 
erable extent  of  surface,  and  possibly  other  injuries  or  impressions  on 
peripheral  nerves,  may  induce  a  reflex  paresis  of  the  arterioles  of  the 
kidneys. 

Symptoms. — More  or  less  pain,  sometimes  very  acute  pain,  is  felt  in 
the  region  of  the  kidneys,  and  extends  downward  along  the  course  of 
the  ureters,  into  the  hips,  through  the  bladder,  which  becomes  very 
irritable,  and  into  the  testicles  and  penis.  There  is  present  an  inces- 
sant and  very  pressing  desire  to  pass  water,  which  is  high-colored,  and 
rather  scanty  each  emission,  although  in  the  aggregate  up  to  the  nor- 
mal. The  urine  may  contain  blood,  or  but  a  few  red  globules,  or 
simply  fibrin  and  casts,  some  cells  of  renal  epithelium  and  albumen. 
If  the  action  of  the  cause  continue,  the  state  of  hypersemia  will  pass 
over  into  some  of  the  forms  of  inflammation.  The  author  is  con- 
vinced that  the  persistent  use  of  copaiba  has  kept  up  an  hypersemia, 
out  of  which  has  developed  the  chronic  form  of  Bright's  disease.  If 
the  agent  producing  the  hypersemia  is  withdrawn,  irritation  subsides 
in  two  or  three  days,  and  health  is  restored. 

The  only  treatment  required  in  the  mildest  cases  is  to  withdraw 
the  irritating  agent,  to  dilute  the  urine  by  the  free  administration  of 
lemonade,  or  Vichy  water,  or  Bethesda  water.  If  there  are  decided 
irritability  of  the  bladder  and  much  pain,  relief  is  quickly  afforded  by 
the  administration  of  two  or  three  grains  of  camphor  every  four  hours, 
or  still  more  promptly  and  efficiently  by  the  hypodermatic  injection  of 
one  twelfth  of  a  grain  of  morphia,  or  by  the  stomach  administration 
of  one  sixth  to  one  fourth  of  a  crrain. 


4,4:2  DISEASES   OF   THE   KIDNEY. 

CONGESTION  OF   THE   KIDNEYS— PASSIVE. 

Causes. — Passive  congestion  of  the  kidneys  is  caused  by  venous 
stasis.  The  chief  lesions  inducing  venous  stasis  are  obstruction  and 
regurgitation  of  the  mitral  orifice,  obstructive  diseases  of  the  lungs, 
obstruction  and  regurgitation  at  the  tricuspid  orifice,  compression  of 
the  ascending  vena  cava  above  the  renal  veins,  and  thrombosis  of  the 
renal  veins. 

Pathological  Anatomy. — The  vessels  are  abnormally  full,  and  hence 
the  organ  is  larger,  and  more  blood  flows  out  on  section.  As  there  is 
a  moister  state  of  the  organ,  owing  to  mechanical  effusion  from  the 
swollen  veins,  the  capsule  is  easily  detached.  The  parenchyma  of  the 
organ  is  darker,  having  a  bluish  aspect  ;  it  is  moist  and  smooth  ;  the 
glomeruli  are  not  swollen  and  congested,  but  the  vessels  of  the  convo- 
luted tubes  are  distended.  The  stellate  vessels  of  the  surface  can  be 
traced  with  the  eye  into  the  anastomoses  of  the  interfascicular  veins, 
and  the  vessels  of  the  vasa  recta  are  recognized  as  dark  reddish  stria- 
tions  (Rindfleisch).  If  hyperaemia  becomes  chronic,  the  over-supply  of 
venous  blood  leads  to  important  nutritional  alterations — -to  hyperplasia 
of  the  connective  tissue — and  hence  the  whole  organ  increases  in  size, 
firmness,  and  weight. 

Symptoms. — In  cases  of  passive  congestion  of  the  kidneys,  the  cen- 
tral disorder  quite  masks  the  changes  occurring  in  the  kidneys.  When 
dropsy  occurs,  attention  is  directed  to  the  state  of  the  urinary  secre- 
tion, but  previously  no  symptoms  had  arisen  indicating  that  the  kid- 
ney was  suffering.  Besides  the  venous  stasis  and  increased  pressure  in 
the  venous  system,  the  disturbance  in  the  urinary  function  is  in  part 
due  to  the  diminished  pressure  in  the  arterial  system.  The  urine  is 
scanty,  dark  in  color,  and  acid  in  reaction.  On  standing,  a  very  abun- 
dant deposit  of  urates  takes  place,  and  the  urine  becomes  thick.  The 
specific  gravity  is  increased  in  the  ratio  of  the  decrease  in  the  urinary 
water,  and  is  1025  to  1035,  but  it  is  also  high  because  of  the  quantity 
of  solids,  uric  acid,  notably  of  urea,  which  may  rise  to  five  per  cent.,  or 
higher.  An  important  change  now  is  apparent  in  the  composition  of 
the  urine — it  contains  more  or  less  albumen,  but  not  often  any  consid- 
erable amount.  If  such  urine,  thick  and  dark,  is  placed  in  a  test-tube 
and  gently  heated,  it  will  soon  clear  up,  except  some  fine  particles,  but 
gradually,  the  heat  continued,  the  clear  urine  will  become  milky,  from 
the  coagulation  of  albumen.  The  urates  dissolve  at  the  temperature 
below  the  coagulating  point  of  albumen.  On  microscopic  examination 
the  morphotic  elements  present  in  the  urine  consist  of  a  few  red-blood 
globules,  some  tubular  epithelium,  and  a  few  delicate,  transparent 
casts.  The  amount  of  albumen  present  in  such  urine  does  not  often 
exceed  one  per  cent. 

Course,  Duration,  and  Termination. — The  kidney  complication  in 


ACUTE   PARENCHYMATOUS   NEPHRITIS.  443 

cardiac  and  pulmonary  obstructive  disease  follows  the  fortunes  of  the 
central  lesion.  When  the  cardiac  lesion  is  compensated,  and  the  pres- 
sure rises  in  the  arterial  and  falls  in  the  venous  system,  the  congestion 
of  the  veins  and  the  ischemia  of  the  arteries  of  the  kidneys  will  cease 
— the  urinary  water  will  increase,  and  the  albumen  will  disappear.  If, 
however,  the  central  lesions  be  permanent,  the  condition  of  the  kidney 
will  grow  worse,  the  albumen  increase,  and,  after  a  time,  the  specific 
gravity  will  fall.  Cerebral  symptoms  do  not  arise  from  venous  conges- 
tion of  the  kidney,  because  the  tubular  epithelium  remains  sound  and 
whole,  and  therefore  equal  to  its  function  of  excreting  excrementi- 
tious  materials.  Death  may  occur  from  some  intercurrent  malady,  or 
the  patient  die  exhausted  from  the  persistent  dropsical  accumulation. 

Treatment. — The  management  of  passive  congestion  of  the  kidneys 
is  that  of  the  central  lesion.  It  includes  the  use  of  digitalis,  quinia, 
and  iron,  of  hydragogue  cathartics,  of  warm  baths,  vapor-baths,  and 
pilocarpus,  of  diuretics,  etc.  The  condition  of  the  kidneys  is  improved 
by  those  remedies  which  affect  the  heart  trouble  favorably.  The  ac- 
count already  given  of  the  treatment  of  cardiac  disease  with  dropsy  is 
equally  applicable  here. 


ACUTE   PARENCHYMATOUS   NEPHRITIS. 

Deflnition. — Under  the  head  of  "  Bright's  Disease  "  there  are  in- 
cluded several  acute  and  chronic  affections  of  the  kidneys,  which  agree 
in  the  one  important  characteristic  of  the  urine  containing  albumen. 
According  to  many  authorities,  acute  parenchymatous  nephritis  is  the 
first  stage  of  Bright's  disease  :  it  is  "the  large,  white  kidney,"  "the 
large,  smooth  kidney  "  of  English  authors,  and  corresponds  to  John- 
son's "  acute  desquamative  nephritis."  Although  Charcot  adopts  the 
term  "  parenchymatous  nephritis,"  he  holds  that  we  are  not  yet  pre- 
pared to  name  it  accurately.*  By  Bartels  it  is  designated  "  acute 
parenchymatous  nephritis."  f 

Causes. — To  this  form  of  nephritis  youths  are  more  liable  than  the 
aged.  An  exception  to  this  exists  in  infants,  and  the  liability  con- 
tinues till  middle  life,  and,  indeed,  though  greatly  diminished,  does 
not  entirely  cease  after  this  period.  Heredity  appears  to  have  an  in- 
fluence, although  the  facts  are  not  numerous.  Type  of  constitution 
seems  very  important  among  the  causes.  The  pale,  light-haired,  full 
but  flabby  subjects  of  the  albuminous  type  seem  to  have  a  special  sus- 
ceptibility to  this  form  of  nephritis.  Those  substances  which  cause 
active  hyperaemia  of  the  kidneys,  as  cantharides,  turpentine,  copaiba, 
etc.,  will  induce  inflammation  of  these  organs,  if  they  continue  in 
action  for  a  sufficient  time.     Scarlatina  is  probably  the  most  common 

*  On  "  Bright's  Disease,"  translated  by  Millard.     New  York  :  William  Wood  &  Co. 
I      t  Ziemssen's  "  Cyclopsedia,"  vol.  xv. 


444  DISEASES  OF   THE   KIDNEY. 

cause.  It  is  not  the  character  of  the  epidemic,  nor  the  severity  of  the 
attack  itself,  which  wholly  determines  the  changes  in  the  kidneys,  for 
the  mildest  epidemics  and  the  least  pronounced  cases  may  be  remark- 
able for  the  extent  of  the  renal  complication  ;  yet,  if  the  epidemic  have 
a  malignant  aspect,  there  will  be  more  formidable  cases  of  nephritis. 
As  not  all  cases  of  scarlatina  are  accompanied  by  the  renal  disease, 
there  must  be  some  inherent  bodily  condition,  or  peculiarity  in  the 
structure  of  the  kidneys,  to  account  for  the  result.  The  same  is  true 
of  diphtheria,  in  which  an  inflammation  of  the  kidneys  occurs  in  a  pro- 
portion of  the  cases.  But  in  diphtheria  there  seems  to  be  a  relation 
between  the  severity  of  the  systemic  poisoning  and  the  occurrence  of 
the  renal  complication.  Oertel  maintains  that  the  disease  of  the  kid- 
neys is  due  to  the  transference  to  these  organs  of  "  bacterian  colonies  " 
and  their  subsequent  multiplication.  In  diphtheria,  more  than  in  scar- 
let fever,  there  may  be  albumen  in  the  urine,  without  recognizable 
changes  in  the  structure  of  the  kidneys.  In  analogous  morbid  states 
acute  parenchymatous  nephritis  may  be  produced.  These  are  typhoid, 
erysipelas,  malignant  pustule,  etc. — diseases  due  to  the  reception  and 
development  of  some  specific  infective  material  which,  eliminated  by 
the  kidneys,  excites  inflammation  in  passing  through  these  organs. 
The  skin  and  kidneys  stand  in  intimate  functional  relation  to  each 
other,  and  when  one  is  inactive  the  other  may  act  vicariously  in  its 
stead.  This  physiological  fact  has  a  corresponding  pathological  rela- 
tion. Acute  nephritis  may  be  excited  by  exposure  of  the  body  to  cold 
when  the  skin  is  warm  and  perspiring.  The  sudden  arrest  of  the  skin 
affection  throws  a  greatly  increased  labor  on  the  kidneys  ;  their  ves- 
sels dilate,  and  an  acute  hypersemia  prepares  the  way  for  inflam- 
mation. Pregnancy  is  a  cause  of  acute  parenchymatous  nephritis. 
Usually,  but  not  invariably,  it  is  the  first  pregnancy,  and  it  is  more 
common  in  twin  pregnancies.  It  occurs  in  the  thin,  in  the  robust  and 
plethoric,  in  those  of  low  and  high  degree,  and  under  the  most  varying 
conditions.  Having  occurred  in  one  pregnancy  it  may  happen  again, 
and  not  unfrequently  becomes  a  permanent  malady  pursuing  a  course 
independently  of  pregnancy.  No  satisfactory  explanation  has  thus  far 
been  offered.  That  it  occurs  not  more  frequently  than  one  time  in 
one  hundred  and  fifty  pregnancies  renders  it  probable  that  there  must 
exist  a  renal  or  constitutional  disposition  which  pregnancy  excites  into 
activity. 

Pathological  Anatomy. — The  changes  in  the  structure  of  the  kid- 
ney in  acute  parenchymatous  nephritis  are  much  disputed.  To  render 
clear  the  form  of  the  disease  under  consideration,  it  may  be  repeated 
that  it  is  the  large,  pale,  and  smooth  kidney  of  the  English  writers.  It 
is  increased  in  size,  so  that  it  may  reach  twice  its  normal  weight  and 
volume  ;  the  cortex  is  pale,  grayish-white,  or  a  dull  white  ;  it  is 
smooth,  because  when  the  capsule  is  stripped  off  there  are  no  pits  or 


ACUTE   PARENCHYMATOUS  NEPHRITIS.  445 

elevations  as  occur  in  the  contracted  kidney,  and  its  texture  is  rather 
soft.  There  is  but  little  hypersemia  of  the  cortex  ;  here  and  there 
dark-red  points  are  seen,  or  punctiform  extravasations  ;  but  the  pyra- 
mids are  deeply  congested,  bluish  red,  or  brighter  red,  and  contrast 
strongly  Avith  the  pale  gray  of  the  cortex.  In  other  cases,  according 
to  Bartels,  the  cortex  may  not  be  so  pale,  may  be  reddish  gray  in  con- 
sequence of  a  considerable  hypersemia,  and  there  may  be  between  this 
amount  of  congestion  and  the  dead-white  a  great  deal  of  variation. 

The  changes  ascertained  on  microscopical  examination  are  found 
"  localized  almost  exclusively  in  the  convoluted  tubes  "  (Charcot),  and 
consist  in  cloudy  swelling  of  the  epithelium,  which  remains  in  situ. 
The  change  in  the  apptearance  of  the  epithelium — the  cloudiness — is  due 
to  the  deposit  of  fine  granulations,  and  in  such  large  numbers  that  the 
lumen  of  the  canal  is  almost  closed  by  the  distention  of  the  epithelial 
cells.  The  ends  of  the  tubules  are  also  sometimes  blocked  by  the 
dei)osit  of  fibrin-plugs.  The  convoluted  tubes  also  become  dilated 
and  varicose  by  reason  of  changes  taking  place  in  the  proper  tunics  of 
these  tubes.  The  appearance  of  the  kidney  thus  affected  may  be 
changed  by  localized  or  extensive  fatty  metamorphosis  —  by  fatty 
change  limited  to  a  few  tubes  here  and  there,  or  by  a  general  fatty 
change.  When  thus  altered  the  color  becomes  yellowish,  and,  if 
localized,  gives  to  the  organ  a  granular  appearance,  and  hence  the 
name  applied  to  it  by  Johnson  as  the  fatty  granular  Tcidney ;  if  gen- 
eral, it  becomes  the  large  fatty  kidney.  It  has  been  much  disputed 
whether  the  large,  smooth  kidney  ever  undergoes  an  atrophic  change. 
It  is  held  by  Charcot  that  in  very  rare  instances  an  atrophy  may  be 
effected  by  the  liquefaction  and  disappearance  of  the  fatty  epithelium 
and  the  subsequent  collapse  of  the  tubules. 

Symptoms. — When  parenchymatous  nephritis  occurs  during  the 
course  of  scarlet  fever,  diphtheria,  and  other  febrile  diseases,  the  symp- 
toms are  modified  in  various  respects.  Two  modes  of  onset  are  de- 
scribed when  the  disease  occurs  independently — one  sudden,  with  high 
fever,  aching  pains  in  the  lumbar  region  ;  the  other  slow,  obscure,  and 
with  little  disturbance.  The  first  variety  usually  results  from  taking 
cold  ;  the  patient,  while  heated  and  perspiring,  plunges  into  cold  water 
or  lies  upon  the  damp  ground,  and  in  a  short  time — twelve  to  twenty- 
four  hours — has  some  chilliness,  even  a  rigor,  followed  by  high  fever, 
intense  headache,  pains  in  the  lumbar  region  and  through  the  limbs, 
nausea,  vomiting,  and  anorexia.  The  symptoms  which  attract  atten- 
tion to  the  kidneys  in  either  mode  of  onset  are  the  changes  in  the  char- 
acter of  the  urine.  In  some  cases  the  first  symptom  referable  to  the 
urinary  organs  is  an  extremely  irritable  state  of  the  bladder,  frequent 
desire  to  micturate  ;  a  few  drops  only,  and  these  it  may  be  bloody,  can 
be  passed.  This  symptom  does  not  last  long,  and  is  not  common. 
Usually  there  are  observed  changes  in  the  quantity  of  the  urine,  the 


446 


DISEASES   OF   THE   KIDNEY. 


amount  passed  in  twenty-four  hours  being  variously  reduced  from 
forty  ounces,  the  normal  quantity  for  an  adult,  to  twenty,  ten,  even  five 
ounces,  and  at  the  same  time  important  new  constituents  appear  in  the 
secretion.  There  may  occm*  entire  suppression,  when  the  most  formi- 
dable symptoms  will  arise,  and  death  result  in  a  few  days.  The  urine 
at  the  onset  often  contains  blood,  when  it  presents  various  appearances 
according  to  the  quantity  present  :  it  may  have  a  faint,  smoky  tinge, 
or  -with  this  there  may  be  an  admixture  of  a  reddish  hue,  or  it  may  be 
distinctly  reddish  without  the  smoky  hue,  or  it  may  be  dark,  reddish- 
brown,  almost  black.  When  permitted  to  stand,  a  quantity  of  urates 
fall,  and  with  them  various  morphotic  constituents,  chiefly  blood-cor- 
puscles, entire  or  disintegrated.  The  quantity  of  urea,  as  compared 
with  the  amount  of  urine,  is  much  less  than  normal ;  uric  acid  is  not 
less,  but  the  saline  constituents  are  reduced.  The  gross  amount  of 
solid  constituents  is,  therefore,  below  the  standard  of  health.  The 
reaction  of  the  urine  is  acid  and  the  specific  gravity  is  high,  often 
reaching  1030,  but  this  result  is  due  to  the  diminished  amount  of 


Fig.  32. — Casts  of  Acute  Parenchymatous  Nephritis. 


(Beale.)         Fig. 


3. — Epithelium  from  Convo- 
luted Tubes.  (Beale.) 


water,  since  the  solids  in  the  aggregate  are  below  normal.  In  the 
further  progress  of  the  case,  as  the  amount  of  water  increases,  the 
specific  gravity  falls  ;  but  there  is  an  increase  in  the  solids  and  in  the 
urea  in  the  aggregate,  although  the  quantity  of  each  is  small  in  any 
single  specimen  of  the  urine.  The  decline  in  specific  gravity  may  be 
from  1030  to  1005.  With  the  diminution  of  specific  gravity  or  increase 
of  water  the  acid  diminishes,  the  urine  becoming  very  faintly  acid  or 
neutral.  The  most  characteristic  condition  as  regards  the  urine  is  the 
presence  of  albumen,  in  this  affection  ranging  from  distinct  traces  to 
three  per  cenx.  The  albumen  may  be  absent  at  the  initial  period,  but 
only  for  a  brief  period,  the  aggregate  amount  of  the  urine  being  very 
small.  Besides  albumen  and  blood-globules,  perfect  and  disintegrated, 
there  are  present  casts  of  the  tubules,  of  coagulated  blood,  and  pale, 
transparent,  hyaline  casts,  with  an  occasional  epithelial  cell  adherent. 
The  pale  casts  are  usually  few  in  number,  but  in  the  progress  of  the 


ACUTE   PARENCHYMATOUS   NEPHRITIS.  447 

case  they  are  supplanted  by  large  hyaline  casts  and  numerous  large 
granular  casts.  Usually,  also,  the  sediment  contains  epithelial  cells 
cast  off  from  the  tubes  and  granules  in  great  numbers.  Very  often  it 
is  not  until  oedema  of  the  ankles  and  feet  appears  that  attention  is 
called  to  the  state  of  the  urine,  when  it  is  found  to  be  scanty.  In 
consequence  of  the  diminution  in  the  amount  of  water  separated  by 
the  kidneys,  the  condition  of  the  blood  and  the  rate  of  absorption, 
especially,  the  cellular  tissue  becomes  (Edematous  ;  if  the  patient  is  up, 
the  water  settles  in  the  feet  and  legs  ;  if  recumbent,  it  accumulates  in 
the  lumbar  region  and  hips,  and  may  first,  or  coincidently  with  its 
appearance  elsewhere,  manifest  itself  in  the  eyelids.  Puffiness  of  the 
face,  with  a  peculiar  pallor  of  the  skin,  and  broadening  of  the  bridge 
of  the  nose,  while  the  eyelids  are  swollen,  present  a  striking  appearance 
which  can  hardly  fail  to  be  observed,  and  may  be  the  first  indication 
of  the  cedema.  The  effusion  extends,  the  subcutaneous  areolar  tissue 
becomes  universally  filled,  and  the  great  serous  cavities  are  ultimately 
distended  to  their  utmost. 

The  retention  in  the  blood  of  the  excrementitious  substances  in 
health  discharged  by  the  kidneys  has  a  disastrous  effect.  The  nervous 
system  is  poisoned,  convulsions  (eclampsia)  occur  and  vary  in  severity, 
from  twitching  of  the  muscles  of  the  face  and  of  the  extensors  of  the 
forearms  to  general  convulsions  involving  loss  of  consciousness  and 
clonic  spasms  of  all  the  voluntary  muscular  system.  The  appetite  is 
lost,  and  there  are  usually  nausea  and  protracted  vomiting,  and  some- 
times there  is  very  troublesome  diarrhoea.  The  loss  of  albumen  and  of 
blood  and  the  poisoning  of  the  blood  by  retained  excrementitious  mat- 
ters soon  lower  very  seriously  the  nutrition  of  the  body.  Vision  is 
impaired,  both  in  consequence  of  simple  ansemia  of  the  retina  and  of 
the  changes  of  albuminuric  retinitis. 

Course,  Duration,  and  Termination. — Those  cases  occurring  sponta- 
neously are  more  acute  in  character,  accompanied  by  fever  and  disor- 
ders of  micturition,  which,  attract  attention  to  the  kidneys.  The  fever 
does  not  continue  longer  than  a  few  days.  If  there  is  complete  sup- 
pression, the  case  may  terminate  fatally  within  a  week.  If,  as  is  usual, 
the  development  is  slower  and  the  urine  is  greatly  diminished  in  quan- 
tity, the  amount  of  the  dropsy  will  depend  on  the  reduction  of  urine 
for  a  lengthened  period.  The  promptness  with  which  oedema  appears 
is  determined  by  the  scantiness  of  the  urine,  so  that  well-developed 
dropsy  may  be  produced  in  a  week.  When  the  cellular  tissue  and  the 
cavities  are  filled  with  fluid,  the  duration  of  the  case  depends  on  the 
degree  in  which  the  kidneys  can  be  made  to  functionate,  for,  although 
temporary  improvement  and  alleviations  may  result  from  vicarious  dis- 
charge of  the  urinary  functions,  results  obtained  in  this  way  are  not 
permanent.  This  form  of  nephritis  is  not  nearly  so  fatal  as  the  other 
forms  ;  indeed,  the  percentage  of  recoveries  is  quite  large.     When  this 


448  DISEASES   OF   THE   KIDNEY. 

disease  occurs  in  scarlatina,  it  modifies  the  courae  of  the  latter  mate- 
rially, and  prolongs  its  duration.  Death  may  ensue  m  convulsions,  or 
result  from  exhaustion  in  consequ.ence  of  the  protracted  ansemia,  and 
the  gastro-intestinal  disturbance,  which  prevents  the  retention  and 
assimilation  of  food.  Recovery  may  ensue  after  several  weeks  of 
dropsy,  vomiting,  and  diarrhoea,  interspersed  with  eclampsia,  the  conva- 
lescence being  very  slow.  Three  months  or  more  may  be  occupied  in 
the  return  to  health. 

The  Acute  Parenchymatous  Nephritis  of  Pregnancy. — There  are 
points  connected  with  this  disease  requiring  special  consideration  in 
respect  to  its  course  and  terminations.  It  is  usually  considered  due 
to  two  factors — to  the  relatively  poor  quality  of  blood  of  pregnant 
women,  and  to  the  pressure  of  the  enlarging  uterus  on  the  renal  veins, 
causing  passive  congestion.  As  Bartels  shows,  the  renal  veins  occupy 
a  position  which  secures  them  against  pressure,  and,  as  so  large  a  pro- 
portion of  pregnant  women  escape  the  complication  of  albuminuria,  it 
can  hardly  be  due  to  either  or  both  of  the  factors  to  which  it  is  usually 
ascribed.  There  must  be  some  special  predisposition,  and  as  the  con- 
dition of  the  kidney  is  precisely  the  same  as  in  the  acute  parenchyma- 
tous nephritis,  and  as  it  not  unfrequently  assumes  the  chronic  form, 
pregnancy  is  merely  an  exciting  cause.  The  change  in  the  kidneys 
may  take  j^lace  in  the  early  months  of  pregnancy,  when  visual  disturb- 
ances, dropsy,  and  miscarriage  will  ensue,  or  later,  when  to  the  visual 
disturbances  and  dropsy  must  bo  added  eclampsia.  (Edema  of  the 
face  and  limbs  and  frequent  micturition  are  often  the  first  symptoms, 
but,  in  the  ajithor's  experience,  visual  disorders,  especially  hemiopia, 
double  vision,  and  amblyopia,  are  very  frequently  the  fii'st  departure 
from  health.*  Again,  persistent  huskiness  of  the  voice  may  be  the 
first  indication.  In  other  cases  no  symptoms  are  felt  but  disorders  of 
digestion,  and,  as  they  are  like  those  of  the  first  months  of  pregnancy, 
little  attention  is  paid  to  them,  or  there  may  be  persistent  headache 
with  vertigo.  Sometimes  the  first  symptom  to  attract  attention  is  an 
attack  of  convulsions,  the  health  being  apparently  good.  The  urine 
usually  contains  an  excessive  quantity  of  albumen.  The  csdema  is 
usually  not  great.  The  important  point  in  these  cases  is  the  violence 
and  acuteness  of  the  urgemia,  whether  manifest  in  the  form  of  convul- 
sions or  maniacal  excitement.  The  relative  frequency  of  eclampsia  in 
proportion  to  the  whole  number  of  cases  of  albuminuria  is  about  one 
fourth,  and  of  those  attacked  by  eclampsia  about  one  third  die.  The 
symptoms  usually  quickly  subside  on  abortion  or  delivery,  but  a  con- 
siderable proportion  become  chronic  and  prove  fatal  in  subsequent 
pregnancies,  f 

*  See  "  Die  Albuminuric  in  ihren  ophthalmoskopischen  Erscheinungen,"  by  Dr.  Hugo 
Magnus,  in  which  the  changes  in  the  retina  wrought  by  albuminuria  are  well  depicted, 
f  Elliot,  "  Obstetric  Clinic,"  chapter  iii.  New  York,  1868. 


ACUTE   PARENCHYMATOUS  NEPHRITIS.  449 

Treatment. — As  the  kidneys  are  in  an  irritated  state,  all  stimulants 
to  them  should  be  avoided.  To  give  them  rest,  vicarious  functions 
need  to  be  stimulated  to  the  highest  activity — notably  the  skin  and 
intestinal  mucous  membrane.  When  the  symptoms  are  urgent,  the  skin 
may  be  excited  by  pilocarpine  nitrate  (^  to  -^  gr.  for  an  adult),  or  by 
the  vapor-bath  or  wai-m  pack.  As  Barker,  of  New  York,  has  recently 
shown,  pilocarpine  must  be  used  with  caution  in  these  cases  on  account 
of  its  depressing  effect  on  the  heart.  Those  purgatives  are  used  that 
produce  free  watery  evacuations.  If  the  stomach  is  very  irritable  and 
the  symptoms  not  urgent,  small  doses  of  calomel  {^  grain),  frequently 
repeated,  act  extremely  well.  In  acute  urremia,  the  most  active  cathar- 
tics are  required — as  elaterium,  croton-oil,  gamboge,  etc. — since  it  is 
necessary  to  procure  abundant  watery  evacuations.  If  the  case  does 
not  require  immediate  active  interference,  the  compound  jalap  powder 
is  probably  the  most  generally  useful  of  the  purgatives  in  this  disease. 
It  is  best  administered  in  the  early  morning,  so  that  the  disturbance 
produced  by  it  may  be  ended  before  the  time  for  the  administration 
of  the  other  remedies  directed  during  the  day.  To  relieve  the  kid- 
neys of  congestion,  and  to  remove  obstructions  from  the  tubules, 
diluents  must  be  freely  used.  The  most  important  diluents  are  milk 
and  cream-of -tartar  solution.  If  the  stomach  is  irritable,  milk  may  be 
given  with  lime-water,  one  fourth  to  one  third  of  the  latter.  Infusion 
of  digitalis  may  be  given  with  cream-of -tartar  solution,  or  alone  ;  but 
it  is  more  effective  in  combination.  If  the  stomach  will  not  bear 
digitalis,  it  acts  surprisingly  well  in  the  form  of  a  poultice  applied  to 
the  back  or  abdomen. 

If  eclampsia  occur,  what  treatment  is  most  effective  ?  If  the  sub- 
ject is  plethoric,  the  superficial  veins  full,  the  conjunctiva  injected, 
bleeding,  by  venesection,  may  be  practiced  with  advantage.  Chloi'o- 
form,  by  inhalation,  can  be  used  to  abate  the  violence  of  the  symp- 
toms, but  as  soon  as  possible  an  hypodermatic  injection  of  morphia 
should  be  given  according  to  the  method  of  Dr.  Loomis,  of  New  York, 
who  has  shown  that  large  doses  are  remarkably  effective  in  arresting 
the  convulsions  of  uraemia.  Half  a  grain  of  morphia  can  be  given  at 
once,  and  it  may  be  repeated  in  two  or  three  hours,  if  necessary,  until 
two  grains  have  been  taken.  He  shows  that,  if  the  first  large  dose  is 
without  effect,  other  doses  should  be  administered  fearlessly  until  the 
desired  effect  is  produced.  Warm  baths  and  active  purgatives  are  in- 
dicated, and  must  be  energetically  used.  Excellent  results  have  been 
obtained  by  the  use  of  chloral  by  the  stomach  (gr.  xv  to  gr.  xlv),  or, 
if  that  organ  "is  rebellious,  by  the  rectum.  Bromide  of  potassium  may 
be  given  in  full  doses,  with  or  without  chloral,  by  the  stomach  or  rec- 
tum, according  to  the  condition  of  affairs.  The  same  principles  hold 
good  in  the  treatment  of  the  puerperal  mania  arising  from  urgemic 
intoxication. 
29 


450  DISEASES   OF   THE   KIDNEY. 

CHRONIC   PARENCHYMATOUS  NEPHRITIS. 

Causes. — It  is  comparatively  rare  for  the  chronic  form  of  paren- 
chymatous nephritis  to  succeed  to  the  acute.  It  is  a  disease  of  youth, 
and  is  rare  after  forty.  It  arises  from  those  causes  which  depress 
more  or  less  permanently  the  vital  forces,  as  syphilis,  chronic  malarial 
]3oisoning,  protracted  suppuration,  chronic  alcoholismus,  chronic  mer^ 
curialismus,  and  other  chronic  poisoning  by  metals,  etc. 

Pathological  Anatomy. — To  this  form  of  diseased  kidney  is  the  term 
large,  pale,  or  white,  smooth  kidney,  especially  applicable.  One  or 
both  may  be  affected.  The  capsule  is  thin  because  of  prolonged 
stretching,  and,  when  divided,  flies  apart  and  is  easily  detached.  The 
cortex  is  a  dull,  rather  yellowish-white  color,  and  is  anaemic,  while 
the  pyramids  are  full  of  distended  vessels  and  are  dark  red.  The 
enlargement  is  due  chiefly  to  an  increased  thickness  of  the  cortical 
part.  The  epithelial  lining  of  the  tubules  is  not  simply  affected  with 
"  cloudy  swelling,"  as  in  the  acute  form,  but  has  undergone  important 
changes — has  been  either  detached,  or  is  far  advanced  in  fatty  degen- 
eration, the  cells  being  filled  with  fat-globules.  The  tubules  are  filled 
with  a  detritus,  the  product  of  the  destruction  of  the  epithelium,  and 
consists  largely  of  .oil-globules,  and  they  also  are  seen  to  be  blocked  in 
places  by  large  casts.  The  intertubular  matrix  is  also  greatly  thick- 
ened— a  change  due  to  hyperplasia  of  the  connective-tissue  elements, 
to  the  migration  of  the  white  corpuscles  and  their  subsequent  multi- 
plication and  fatty  transformation,  and  to  a  quantity  of  fluid  exuda- 
tion, the  product  of  the  increased  pressure  in  the  veins.  The  Mal- 
pighian  tufts  and  arteries  are  sometimes  affected,  according  to  Bartels, 
with  the  amyloid  change  in  cases  arising  from  chronic  suppuration.* 
Undoubtedly,  many  tubules  are  rendered  entirely  and  permanently 
useless,  but  restoration  may  take  place  when  extensive  changes  have 
occurred  in  the  kidneys.  But,  when  the  changes  are  too  far  advanced 
to  permit  recovery,  the  increase  in  the  intertubular  connective  tissue 
and  its  subsequent  contraction  bring  about  an  atrophic  degeneration. 

Symptoms. — The  approach  of  this  form  of  kidney-disease  is  insid- 
ious. There  is  some  decline  in  strength,  the  body  is  more  easily 
fatigued,  the  mind  is  rather  sluggish,  and  the  appetite  is  poor.  A 
condition  of  anaemia  is  evident,  and  the  face  has  an  earthy  or  fawn 
color,  but  it  is  not  until  oedema  appears  about  the  eyelids  and  ankles 
that  advice  is  sought  and  the  real  nature  of  the  case  made  apparent. 
The  accumulation  of  fluid  now  proceeds  rapidly,  and  in  a  short  time 
the  whole  body  is  greatly  swollen.  The  cellular  tissue,  the  penis,  and 
scrotum  are  immensely  distended,  and  afterward  the  cavities  fill  up  to 
their  utmost  capacity,  and  death  may  be  soon  caused  by  oedema  of  the 

*  Rindfleisch,  while  admitting  the  existence  of  amyloid  change,  regards  it  as  "  infre- 
<luent."     {Op.  cit.) 


CHRONIC  PARENCHYMATOUS  NEPHRITIS. 


451 


lungs  or  paralysis  of  the  heart.  The  dropsy  in  this  form  of  nephritis 
assumes  much  greater  proportion  than  that  of  the  acute,  or  indeed  of 
any  form  of  nephritis.  As  the  accumulation  of  fluid  increases,  the 
amount  of  urine  discharged  diminishes,  but  the  urine  falls  off  with  the 
beginning  of  the  renal  lesions,  although  the  change  is  not  enough  to 
attract  attention.  \Yhen  the  disease  attains  its  maximum,  the  quan- 
tity of  urine  passed  in  twenty-four  hours  becomes  exceedingly  small, 
and  may  not  exceed  four  ounces,  but  there  is  considerable  fluctuation, 
due  to  the  variations  in  the  amount  of  water.  The  urine  has  a  darkish, 
smoky-looking  color,  which  deepens  as  the  quantity  lessens.  As  the 
urine  cools,  it  becomes  thick  with  urates,  epithelium,  casts,  etc.     The 


Fig.  34.— Casts.    (Beale.) 

sediment,  which  falls  in  great  quantity,  is  composed  of  urates,  uric. 
acid,  casts,  white-blood  globules,  and  granular  detritus.  The  casts  at 
first  consist  of  pale,  delicate  hyaline  cylinders,  dotted  here  and  there 
with  oil  drops  or  granules,  either  long,  narrow,  and  cuiwed,  or  broad 
and  shorter.  The  casts  change  in  character  with  the  progress  of  the 
case,  becoming  more  granular,  fatty,  and  the  broad  replacing  the  nar- 
row casts.  The  specific  gravity  of  the  urine  changes  with  the  variations 
in  the  quantity  of  urinary  water,  rising  to  1035,  even  1040,  when  the 
amount  of  urine  discharged  is  very  small.  If,  from 
any  cause,  there  is  a  considerable  increase  in  the 
quantity  of  urine,  the  specific  gravity  falls  corre- 
spondingly, and  below  the  normal.  Albumen  is  al- 
ways present,  but  not  in  very  great  quantity,  and 
fluctuates  in  amount  with  the  variations  in  the  spe- 
cific gravity.  The  same  fact  is  true  of  urea,  which, 
while  constantly  and  absolutely  below  the  normal,  fig.  85.— Casts  becoming 
varies  with  the  changes  in  the  specific  gravity  of  the  ^  ^' 

urine.     The  uric  acid  is  increased,  and  probably  in  the  ratio  of  the 
diminution  of  the  urea. 

When  the  dropsical  accumulation  has  reached  the  maximum,  the 
fluid  is  not  limited  to  the  subcutaneous  tissue  and  the  cavities.  The 
mucous  membranes  become  similarly  affected.  An  early  symptom 
may  be  a  husky,  even  toneless  voice,  and  dangerous  laryngeal  stenosis, 
from  oedema  of  the  glottis.     The  lungs  become  more  or  less  oedema- 


452  DISEASES   OF   THE   KIDNEY. 

tous  at  the  height  of  the  disease,  and  life  may  be  terminated  by  the 
accumulation  of  fluid  in  the  lungs.  The  gastro-intestinal  mucous 
membrane  is  also  dropsical,  and  the  epithelium,  swollen,  sodden,  and 
dep-enerating,  is  cast  off  in  large  quantity.  The  result  is  vomiting  of 
a  quantity  of  serous  fluid  and  profuse  serous  evacuations  from  the 
bowels,  not  only  exhausting  in  themselves,  but  causing,  ultimately, 
greater  depression  by  interfering  with  digestion  and  the  assimilation 
of  food.  The  external  integument  is  similarly  affected.  The  epider- 
mis is  sodden  and  detached  ;  the  skin  cracks  in  places,  permitting  the 
water  to  drain  through  ;  and  the  true  skin,  irritated  and  exposed,  be- 
comes exceedingly  painful.  This  process  takes  place  especially  where 
the  enormously  distended  scrotum  lies  on  the  swollen  thighs.  An 
extreme  degree  of  anaemia  results,  from  the  operation  of  the  various 
influences  at  work,  in  the  digestive  functions,  in  the  assimilative  func- 
tions, in  the  blood  itself,  and  in  the  respiratory  functions.  The  body, 
though  puffed  up  with  water,  is  thin,  emaciated,  and  feeble.  The 
pulse  is  small,  compressible,  and  frequent.  At  the  beginning  of  the 
disease,  commencing  rather  abruptly  in  healthy  and  vigorous  subjects, 
the  pulse  may  be  slow  and  full,  and  the  heart-sounds  sharply  accentu- 
ated and  loud,  but,  when  well  advanced,  in  all  cases  the  pulse  has  the 
characteristics  just  mentioned,  and  the  heart-sounds  are  feeble  and 
.obscure.  When  oedema  of  the  lungs  takes  place,  the  respiration  be- 
comes embarrassed ;  but,  if  large  serous  accumulations  occur  in  the 
pleural  cavities  and  in  the  pericardium,  the  breathing  becomes  very 
diflicult,  the  patient  is  unable  to  lie  down,  and  is  tormented  by  a  feel- 
ing of  impending  suffocation.  Ursemia  does  not  occur  so  frequently 
in  the  chronic  as  in  the  acute  form  of  the  disease,  but  amaurosis,  mus- 
cular twitching,  and  partial  and  general  convulsions  do  now  and  then 
take  place. 

Course,  Duration,  and  Termination. — Commencing  insidiously,  it  is 
not  until  dropsical  symptoms  are  manifest  that  the  nature  of  the  case 
is  declared.  Rarely  does  the  disease  come  on  with  boisterous  symp- 
toms, the  body  becoming  rapidly  distended.  When  the  oedema  is  ob- 
served, there  is  no  long  interval  in  any  case  until  the  dropsy  is  general. 
When  the  maximum  distention  is  reached,  life  can  not  long  continue 
without  relief.  Dropsy,  however,  does  not  appear  at  once  in  every 
case  —  albuminuria  may  exist  for  months  without  any  effusion,  but, 
when  this  is  the  case,  there  may  properly  be  a  suspicion  that  an  error 
of  diagnosis  has  been  committed.  In  favorable  cases  the  dropsy  will 
not  be  so  great,  and  the  kidneys  will  manifest  a  disposition  to  activity, 
and  will  respond  to  the  action  of  medicines.  Those  are  unfavorable 
cases  in  which  the  dropsical  accumulation  is  extreme,  and  the  kidneys 
are  sluggish,  but  little  urine  passing,  and  in  which  these  organs  can  not 
be  induced  to  act  efficiently.  When  there  is  pronounced  dropsy,  if 
the  urine  increases  and  the  effusion  diminishes,  a  year  or  more  must  be 


CHRONIC   PARENCHYMATOUS  NEPHRITIS.  453 

expected  to  pass  before  recovery  can  ensue.  A  complete  recovery  is 
a  rare  event.  Usually,  wlien  the  dropsy  disappears,  and  convalescence 
is  apparently  established,  there  ai-e  yet  albumen  and  casts  in  the  urine. 
If  this  is  the  case,  the  recovery  is  not  real  :  there  may  be  a  slow  return 
of  flesh,  the  cachexia  may  diminish,  and  the  strength  improve,  but  a 
return  of  the  dropsy  may  be  confidently  expected.  Usually,  when  the 
albumen  persists  in  the  urine,  the  health  is  not  restored  when  the 
dropsy  disappears,  but  the  body  continues  emaciated,  and  the  pallor 
and  anaemia  remain.  Death  may  be  due  to  some  intercurrent  malady 
— to  an  acute  serous  inflammation,  to  a  low  grade  of  pneumonia,  etc.  ; 
or  the  patient  may  be  worn  out  and  die  by  exhaustion  ;  or  death  may 
be  due  to  ursemic  coma.  That  the  last-named  accident  does  not  occur 
more  frequently  is  probably  due  to  the  fact  that  the  excrementitious 
urinary  substances  are  contained  in  the  fluids  of  dropsy. 

Diagnosis. — When  the  symptoms  occur  suddenly,  there  is  feverish- 
ness,  the  urine  contains  blood  and  pale  casts,  and  there  is  pain  in  the 
back,  the  form  of  the  disease  is  acute.  If  the  symptoms  come  on 
slowly,  there  is  no  fever,  no  blood  or  epithelial  cells  are  present  in  the 
urine,  the  quantity  of  albumen  small  and  the  specific  gravity  high,  or 
over  1030,  the  form  of  the  disease  is  chronic.  In  contracted  kidney, 
the  urine  is  pale,  of  low  specific  gravity,  and  contains  waxy  casts  ;  in 
chronic  parenchymatous  nephritis  the  urine  is  dark,  of  high  specific 
gravity,  and  contains  abundant  large  granular  casts  and  epithelium  : 
in  the  former  there  is  but  slight  or  no  dropsical  accumulation  ;  in  the 
latter  the  dropsy  is  extensive. 

Prognosis. — Although  decidedly  unfavorable,  the  prognosis  is  not 
hopeless.  Cases  have  recovered  in  which  there  had  been  very  pro- 
nounced dropsy,  and  in  which  albumen  had  remained  in  the  urine  for 
months  after  the  disappearance  of  the  effusion.  The  more  acute  the 
symptoms  and  sudden  the  accumulation  of  fluid,  the  more  favorable, 
provided  the  kidneys  exhibit  any  activity.  The  prognosis  is  the  more 
favorable,  the  shorter  the  duration  of  the  disease,  the  less  the  urine  de- 
parts from  the  standai*d  of  health,  and  the  smaller  the  percentage  of  al- 
bumen. When  the  probable  cause  is  remediable,  as  syphilis,  or  marsh- 
miasm,  or  lead-cachexia,  the  prognosis  is  favorable  in  proportion  to  the 
degree  in  which  the  morbid  changes  are  due  to  the  action  of  these  causes. 

Treatment. — A  dry,  unchangeable,  and  warm  climate  exercises  a 
most  favorable  influence  on  the  course  and  termination  of  chronic 
parenchymatous  nephritis,  and  is  a  remedial  agent  of  the  first  impor- 
tance. When  a  suitable  climate  can  not  be  obtained,  the  conditions 
which  render  it  so  useful  should  be  applied  to  the  patient,  if  practi- 
cable. He  should  be  confined  to  bed,  and  remain  between  blankets,  to 
secure  warmth  and  uniformity.  Free  diaphoresis  should  be  produced 
by  wann  air  and  by  the  administration  of  pilocarpus.  If  the  accumu- 
lation of  fluid  is  excessive,  free  purgation  will  be  necessary,  but  this 


454  DISEASES  OF   THE   KIDNEY. 

measure  can  not  be  continued  for  any  lengthened  period,  since  the  im- 
plication of  the  mucous  membrane  is  such  that,  without  purgatives, 
there  occurs  a  highly  irritable  state  of  the  intestinal  canal.  Besides 
diaphoresis,  the  only  resource  now  remaining  is,  to  stimulate  diuresis. 
The  choice  of  diuretics  is  restricted  to  those  which  do  not  increase  the 
blood-pressure  in  the  kidneys — as  the  free  imbibition  of  fluids,  milk, 
bitartrate-of-potassa  solution,  etc.  The  infusion  of  digitalis,  notwith- 
standing the  theoretical  objections  to  it,  is  often  very  serviceable  in 
exciting  free  diuresis.  Combination  with  the  bitartrate  or  acetate  of 
potassa  increases  the  action  of  both  agents.  If  there  be  great  disten- 
tion of  the  cavities  and  increasing  difficulty  of  breathing,  the  aspirator 
may  be  used  freely  to  draw  off  sufficient  fluid  to  afford  relief,  but  it  is 
not  desirable  to  empty  the  cavities.  The  removal  of  the  fluid  in  the 
peritoneal  cavity  usually  suffices,  since  the  upward  pressure  of  the 
ascites  is  the  chief  factor  in  the  difficulty  of  breathing.  Puncture  of 
the  skin  may  be  necessary  when  the  penis  and  scrotum  are  greatly  dis- 
tended, but  care  must  be  used  lest  sloughing  follow,  A  small  sewing- 
needle  is  employed  to  puncture  the  skin,  but  Southey's  trocar  may 
be  used,  as  it  is  a  neat,  elegant,  and  efficient  instrument  for  the  pur- 
pose. If  the  fluid  can  be  removed  by  the  application  of  these  reme- 
dies, iron  should  now  be  used  to  correct  the  anaemia.  Combination 
with  iron  increases  the  action  of  diuretics.  As  the  presence  of  albu- 
men after  the  disappearance  of  the  dropsy  indicates  the  persistence  of 
the  mischief  in  the  kidneys,  it  is  then  necessary  to  employ  remedies  to 
check  the  waste  of  material  and  to  remove  the  cause  on  which  it  de- 
pends. This  is  a  difficult  if  not  an  impossible  task.  The  author  has 
had  promising  results  from  the  careful  administration  of  tincture  of 
cantharides — five  drops  ter  in  die,  and  continued  if  the  results  are 
favorable,  for  several  months.  Recent  reports  have  favored  the  use 
of  methaniline,  but  the  author's  experience  has  not  been  confirmatory. 
Good  results  have  also  been  claimed  for  the  Blatta  Orientalis — the 
cockroach — a  new  remedy  which  comes  to  us  from  Russia. 

INTERSTITIAL   NEPHRITIS— SCLEROSIS   OF  THE   KIDNEYS. 

Definition. — Interstitial  nephritis  is  one  of  the  chronic  forms  of 
Bright's  disease.  Various  designations  have  been  applied  to  it :  fibroid 
kidney,  renal  cirrhosis,  contracting  kidney,  granular  kidneys,  etc.  The 
terms  above  given — interstitial  -nephritis  and  sclerosis  of  the  kidneys 
— are  correct,  since  they  designate  the  seat  and  character  of  the  morbid 
change — an  inflammation  of  the  connective  tissue  of  the  kidney,  the 
subsequent  atrophy  being  due  to  the  contraction  and  pressure  of  the 
new  elements. 

Etiology. — This  disease,  like  its  congener,  sclerosis  of  the  liver,  is  a 
malady  of  middle  life,  according  to  Dickinson  occurring  with  greatest 


INTERSTITIAL   NEPHRITIS.  455 

frequency  at  fifty,  and  rarely  before  twenty.  As  regards  sex,  this  disease 
is  twice  as  frequent  in  men  as  in  women  (Dickinson  *),  and,  according 
to  German  writers,  four  times  more  frequent  in  men  (Bartels).  Social 
condition  does  not  appear  to  have  any  relation  to  its  production,  as  it 
occurs  under  all  circumstances  Jn  life.  Gout  seems  to  have  an  impor- 
tant position  as  a  cause  ;  in  sixty-nine  fatal  cases  there  were  sixteen 
due  to  or  accompanied  by  gout  (Dickinson).  The  gouty  condition  is 
produced  in  a  considerable  proportion  of  those  exposed  to  emanations 
from  lead,  and  gouty  kidney  or  granular  kidney  occurs  in  an  astonish- 
ingly large  number  of  such  subjects.  Out  of  forty-two  workers  in  lead, 
dying  from  various  causes  in  St.  George's  Hospital,  twenty-six  had 
granular  kidneys  (Dickinson).  Lead-poisoning  ranks  first  as  a  cause 
of  this  disease.  It  is  in  a  high  degree  probable  that  chronic  poison- 
ing by  other  metals  may  exert  a  similar  if  not  so  predominant  an  in- 
fluence in  the  production  of  this  disease.  While  this  work  is  going 
through  the  press,  an  important  article  has  appeared  in  the  "  American 
Journal  of  the  Medical  Sciences  "  (July,  18S0)  from  Drs.  Da  Costa  and 
Longstreth,  on  "  The  State  of  the  Ganglionic  Centers  in  Bright's  Dis- 
ease," in  which  they  demonstrate  the  existence  of  degenerative  changes 
in  the  renal  ganglia.  The  ganglia  undergo  fatty  degeneration  and 
atrophy,  the  connective-tissue  hyperplasia  and  the  new  elements  pass 
through  the  same  process.  These  lesions  appear  to  the  authors  of  the 
paper  to  stand  in  a  causal  relation  to  the  renal  affection. 

The  author  has  maintained  for  many  years  that  interstitial  nephri- 
tis frequently  follows  gonorrhoea  in  consequence  of  the  injurious  action 
on  the  kidneys  of  the  oils  and  balsams  used  in  its  treatment.  Lieber- 
meister  and  Bartels  have  lately  suggested  that  this  relation  between 
gonorrhoea  and  nephritis  exists,  but  they  suppose  a  transference  of  the 
catarrhal  process  from  the  bladder  to  the  kidneys. 

Pathological  Anatomy. — TVhen  the  disease  is^  far  advanced,  the 
kidneys,  usually  both,  are  very  much  reduced  in  size,  from  six  or  five 
ounces  to  three  or  two.  From  this  extreme  to  a  size  equal  to  or  a  little 
greater  than  the  normal,  the  gradations  are  numerous.  Usually  both 
kidneys  are  equally  affected,  but  it  sometimes  happens  that  the  disease 
is  more  advanced  in  one.  The  capsule  is  thickened,  opaque,  and  some- 
what adherent.  The  surface  of  the  kidney  presents  a  granular  aspect, 
due  to  the  foiTnation  of  a  great  number  of  spherical  prominences,  one 
tenth  of  an  inch  in  size  generally,  but  they  may  be  either  larger  or  smaller 
than  this  figure.  These  prominences  are  grayish  in  color  and  without 
vascularity,  but  the  depressions  between  them  are  very  vascular.  Cysts 
of  various  sizes  and  in  varying  numbers  are  seen  here  and  there  on 
the  surface ;  they  are  clear,  transparent,  and  of  a  straw-color.  On 
section,  the  tissue  of  the  kidney  is  found  to  be  tough  and  resistant. 

*  "The  Pathology  and  Treatment  of  Albuminuria,"  p.  124. 


456  DISEASES   OF   THE   KIDXEY. 

The  cortical  portion  is  thin  by  reason  of  atrophy,  a  line  or  two  in  thick- 
ness only  remaining.  The  color  is  dai-k-brownish,  or  reddish-brown, 
or  a  yellowish -gray  or  fawn  color,  the  variations  being  due  chiefly  to 
the  amount  of  blood  present  in  the  organ.  On  microscopic  examina- 
tion, the  connective  tissue  about  the  Malpighian  bodies  and  the  blood- 
vessels and  beneath  the  capsule  is  thickened,  and  the  tubes  are  com- 
pressed into  mere  threads.  Here  and  there  may  be  a  tube  complete, 
its  epithelium  intact,  but  large  spaces  exist  between,  consisting  exclu- 
sively of  fibrous  tissue,  with  the  mere  remains  of  wasted  tubes.  The 
glomeruli  are  grouped  in  bunches  owing  to  the  wasting  of  the  interme- 
diate tubes,  and  lie  imbedded  in  the  fibrillated  connective  tissue.  Cut 
off  from  the  tubular  connections,  in  some  of  them  fluid  accumulates, 
forming  cysts.  Interior  cysts  as  well  as  those  on  the  exterior  are, 
however,  chiefly  developed  from  obstructed  tubules. 

The  changes  are  not  always  general,  but  may  take  place  in  parts 
of  the  organ  ;  one  extremity  may  be  small,  contracted,  granular,  the 
other  presenting  its  normal  apjDearance  ;  the  hilus  may  be  the  seat  of 
the  change  and  the  rest  of  the  organ  be  affected  in  patches.  These  ex- 
amples of  irregularity  in  the  development  of  the  sclerosis  are  further 
irregular  in  the  fact  that  the  kidneys  are  unequally  involved  in  the 
morbid  process.  The  pathological  alterations  are  not  limited  to  the 
kidneys.  The  left  side  of  the  heart  is  hypertrophied,  and  this  suc- 
ceeds to  or  is  associated  with  hypertrophy  of  the  muscular  fiber  of  the 
arterioles  throughout  the  body.  The  retina  undergoes  a  form  of  in- 
flammation resulting  in  atrophy  of  the  optic  disks,  known  as  retinitis 
alhuminurica.  The  changes  in  the  vessels  are  an  influential  factor  in 
the  production  of  the  cerebral  haemorrhage  with  which  this  disease 
not  unfrequently  terminates. 

Symptoins. — The  development  of  this  disease  is  so  slow  and  from 
such  small  beginnings  that  it  is  usually  far  advanced  before  any  symp- 
toms arise  indicating  the  nature  of  the  malady.  There  may  be,  indeed, 
no  symptom  referable  to  the  kidneys.  A  patient  dies  from  a  cerebral 
haemorrhage,  and  after  death  granular  and  contracted  kidneys  are 
found.  Another  has  convulsive  seizures,  partial  or  general  ;  the  urine 
is  then  examined,  and  albumen  is  found  in  it.  Another  has  headaches, 
his  nose  bleeds,  and  he  suffers  from  indigestion,  acidity,  and  flatulence, 
to  which  his  other  troubles  are  referred.  Another  passes  water  more 
frequently  than  seems  natural,  gets  out  of  bed  frequently  at  night,  and 
seeks  relief  for  these  symptoms.  Another  suffers  from  attacks  of 
difiicult  breathing — asthmatic  they  seem — or  he  gets  out  of  breath  on 
ascending  the  stairs  or  making  any  considerable  exertion  ;  he  has  also 
attacks  of  palpitation  and  a  stridulous  cough,  and  finds  that  he  must 
elevate  his  head  and  chest  to  lie  with  any  comfort  at  night.  And  still 
another  has  vertigo,  headache,  and  disorders  of  vision,  which  come 
on  without  apparent  cause.     The  solution  of  the  problem  is  at  once 


INTERSTITIAL  NEPHRITIS.  45  Y 

afforded  by  an  examination  of  the  urine  and  the  discovery  of  albumen. 
Of  all  these  initial  symptoms,  frequent  micturition,  especially  at  night, 
is  the  most  usual.  The  urine  in  typical  cases  is  pale,  of  low  specific 
gravity,  and  is  large  in  quantity.  The  color  is  faintly  yellow,  or  it.  is 
colorless,  of  very  feeble  acid  reaction  or  neutral,  and  the  specific  gravity. 
falls  to  1003  to  1010.  While  the  daily  quantity  passed  by  a  healthy 
adult  is  about  forty  ounces,  in  this  disease  the  urinary  discharges 
amount  in  twenty-four  hours  to  a  gallon  or  more.  It  is  an  ill-omen 
when  the  urinary  discharge  falls  oil  considerably,  for  this  indicates 
still  greater  damage  to  the  kidneys,  and  bodes  the  onset  of  uraemia. 
The  urine,  as  a  rule,  contains  more  or  less  albumen,  but  it  may  be  ab- 
sent for  days  together,  and  indeed  may  be  absent  for  much  of  the 
time  throughout  the  disease.  Hence  frequent  examinations  must  be 
made,  and  at  longer  intervals,  in  doubtful  cases.  The  amount  of  albu- 
men discharged  is  not  large  at  any  time,  and  in  the  beginning  of  the 
morbid  change  in  the  kidney  may  be  very  small,  so  as  to  produce  but  a 
faint  cloudiness,  and  requiring  the  utmost  nicety  of  observation  to  de- 
tect it.  The  quantity  of  albumen  is  affected  by  diet,  mode  of  life,  and 
by  the  amount  of  the  urinary  discharge.  The  solid  constituents  of 
the  urine,  especially  the  urea,  are  much  reduced  ;  uric  acid  is  also 
present  in  very  small  quantity,  and  the  saline  constituents  are  equally 
light.  Hence  the  urine  appears  clear,  like  water,  and  deposits  little 
sediment.  There  may  be  seen  some  octahedral  crystals  of  oxalate  of 
lime,  an  occasional  epithelial  cell,  and  hyaline  casts.  The  last-men- 
tioned constituent  in  the  sediment  is  most  important.  The  casts  arc 
few  in  number,  and  hence  the  sediment  should  be  collected  from  a  con- 
siderable quantity  of  urine.  They  are  pale,  transparent,  their  outlines 
not  easily  discerned,  and  without  structure,  except  an  occasional  ad- 
herent granule  or  fat-globule.  These  pale,  hyaline  casts  must  be  dis- 
tinguished from  the  pale,  yellow  and  highly  refracting  casts  which 
appear  in  the  urine  in  parenchymatous  nephritis. 

At  first,  in  this  disease,  the  appetite  and  digestion  are  good,  and 
the  nutrition  of  the  body  continues  unimpaired.  Thirst  is  an  early 
symptom.  More  fluid  is  taken  at  meals,  and  at  other  times  a  quantity 
of  water,  which  seems  to  the  patient  to  pass  through  the  body  without 
a  halt.  Presently,  distress  after  eating,  even  epigastric  pain,  flatulence, 
and  irregularity  in  the  stools,  are  experienced.  Acidity,  pyrosis,  de- 
pressing nausea,  with  headache,  come,  as  the  case  progresses,  to  be  very 
constant  symptoms.  The  body-weight  declines,  the  skin  becomes  dry, 
scurfy,  and  of  a  dead  yellowish-white  or  fawn  color,  and  the  hair  ap- 
pears dry  and  lifeless.  The  strength  fails,  and  the  breathing  becomes 
labored  on  making  any  exei'tion.  This  is  due  partly  to  the  losses  of 
material  and  partly  to  the  changes  occurring  in  the  heart.  The  left 
cavities  undergo  hypertrophy,  and  the  arterioles  throughout  the  body 
are  in  a  state  of  abnormally  high  tension,  owing  to  hypertrophy  of 


458  DISEASES   OF   TEE   KIDNEY. 

their  muscular  layer  ;  hence  the  radial  pulse  exhibits  an  exalted  tension 
and  force.  Much  discussion  has  occurred  as  to  the  existence  of  this 
thickening  of  the  muscular  fibers  of  the  tunica  media,  and  as  to  the 
causes,  but  the  fact  seems  now  firmly  established.  The  obstacle  to  the 
circulation  produced  by  the  abnormal  tension  in  the  arterioles  is  the 
chief  if  not  the  only  factor  in  causing  hypertrophy  of  the  left  ven- 
tricle. Toward  the  end,  however,  a  change  takes  place  in  the  hyper- 
trophied  muscle  :  it  undergoes  fatty  degeneration  ;  then  the  cardiac 
movements  become  weak,  the  sounds  indistinct,  and  the  circulation 
feeble.  In  this  form  of  kidney-disease  there  is  usually  no  dropsy.  It 
is  true,  cedema  may  occur  from  various  complicating  conditions,  if  not 
from  the  kidney-disease.  When  urine  can  no  longer  be  separated  from 
the  blood  by  the  damaged  organs  there  will  be  dropsy,  but  death  takes 
place  by  the  phenomena  of  uraemia.  When  some  lesion  of  a  valve  oc- 
curs, especially  if  of  the  mitral,  cedema  will  appear  in  the  ankles  and 
face.  Pleural  inflammation  or  hepatic  disease  may  result  respectively 
in  hydrothorax  or  ascites.  Although  the  dropsy  is  never  sufficient  to 
cause  death — is  never  anything  more  than  an  cedema  of  the  face  and 
extremities — yet  death  may  be  due  to  a  sudden  oedema  of  the  lungs. 
When  the  case  is  approaching  its  termination,  the  symptoms  of  ursemia 
develop.  The  nausea  which  had  existed  before,  with  occasional  vomit- 
ing, increases,  becomes  incessant,  and  the  vomiting  is  violent  and  un- 
controllable. The  vomiting  is  not  necessarily  excited  by  the  presence 
of  food  ;  it  occurs  when  the  stomach  is  empty,  in  the  early  morning  ; 
and  after  severe  and  protracted  retching  only  a  little  mucus,  with  a 
quantity  of  watery  fluid  of  low  specific  gravity  and  very  feeble  acidity, 
comes  up.  Diarrhoea  also  now  gradually  increases,  and  toward  the 
end  becomes  uncontrollable,  the  stools  being  thin,  abundant,  and  fre- 
quent. At  last  the  evacuations  consist  of  a  watery  fluid,  with  some 
mucus,  and  very  little  fecal  matter,  and  occur  involuntarily.  The  vom- 
iting and  purging  are  largely  vicarious  of  the  urinary  secretion,  which 
contains  less  and  less  solid  matter.  The  profuse  discharges  are  very 
exhausting,  and  consequently  serve  to  develop  the  symptoms  proper  to 
ursemia.  There  is,  now,  an  increasing  headache  ;  much  vertigo  is  ex- 
perienced ;  hebetude  of  mind  and  a  soporose  state  came  on,  so  that 
when  his  attention  is  withdrawn  from  persons  and  things  the  patient 
falls  asleep  in  his  chair,  but  sleep  at  night  is  disturbed  by  vivid  dreams, 
and  there  are  much  muscular  twitching,  jerking,  and  heavy,  irregular 
breathing.  Unsymmetrical  convulsive  movements,  jactitations  of  indi- 
vidual muscles,  and  groups  of  muscles,  of  the  face  or  extremities,  and 
general  convulsions,  occur  as  the  case  approaches  the  end.  The  patient 
when  fully  aroused  may  still  be  entirely  conscious,  but  he  soon  lapses 
into  stupor  when  left  to  himself  ;  there  may  be  maniacal  delirium 
and  violent  struggling,  or  unconsciousness  between  the  convulsive 
seizures.     An  early  symptom  in  many  cases  of  interstitial  nephritis  is 


INTERSTITIAL   NEPHRITIS.  459 

amblyopia,  double  vision,  hemiopia,  and  other  derangements  of  vision. 
As  has  been  pointed  out,  these  symptoms  may  be  the  first  to  attract 
attention,  so  that  the  diagnosis  is  made  by  the  oculist.  When  the  ex- 
amination is  made  by  the  ophthalmoscope  at  an  early  period,  the  optic 
disks  are  found  to  be  swollen  ;  the  veins  are  enlarged  and  tortuous, 
while  the  arteries  are  rather  shrunken.  Whitish  spots  appear  on  the 
retina,  of  various  sizes,  and  hemorrhagic  extravasations  occur  along 
the  vessels,  but  both  chiefly  about  the  disks  and  in  the  neighborhood 
of  the  macula  lutea.  Both  eyes  are  affected,  but  in  vaiying  degrees.* 
While  these  obvious  changes  occur  during  the  course  of  the  disease, 
and  are  permanent,  there  are  fugitive  attacks  in  which  vision  may  be 
lost  without  any  retinal  changes.  Just  as  there  may  be  muscular 
twitchings,  and  even  convulsions,  without  any  permament  lesions,  so 
there  may  be  entire  loss  of  vision  without  any  alterations  of  the  retina. 

Course,  Duration,  and  Termination. — Interstitial  nephritis  is  a  very 
chronic  malady.  There  is  a  long  period  (often  several  years)  from 
the  beginning  of  frequent  micturition  to  the  occurrence  of  impaired 
functions  elsewhere.  In  those  cases  marked,  as  has  been  pointed  out, 
by  violent  initial  symptoms,  the  disease  in  the  kidneys  has  proceeded 
silently,  and,  interfering  with  no  function,  has  caused  no  disturbance 
until  the  sudden  outbreak.  It  sometimes  happens  that  a  man  falls  in 
the  street,  is  violently  convulsed,  and  dies  in  a  few  hours  comatose, 
the  real  lesion  in  the  kidney  having  gone  on  unobserved  for  months 
and  years,  it  may  be.  The  duration  of  the  disease  can  not,  therefore, 
be  definitely  expressed.  The  termination  is  most  usually  with  uraemia 
— convulsions,  coma,  and  death.  The  changes  in  the  vessels  and  the 
hypertrophy  of  the  heart  are  the  causes  of  cerebral  hemorrhage  with 
w^hich  many  cases  end.  The  excrementitious  matters  circulating  in 
the  blood  give  rise  to  inflammations  of  the  serous  membranes,  notably 
pericarditis  and  endocarditis,  which  prove  fatal.  Death  may  be  caused 
by  hemorrhages  from  the  mucous  surfaces,  or  from  the  exhaustion 
caused  by  violent  vomiting  and  purging. 

Diagnosis. — The  recognition  of  this  disease,  when  the  existence  of 
albuminuria  has  been  ascertained,  can  never  be  difiicult.  The  large 
quantity  of  urine,  the  absence  of  color,  the  low  specific  gravity,  the 
small  amount  of  albumen,  the  hyaline  casts,  the  hypertrophied  heart 
and  arterioles,  are  to  be  compared  with  the  small  quantity  of  urine, 
the  high  color,  the  high  specific  gravity,  the  immense  quantity  of  al- 
bumen and  granular  casts,  the  rapid,  large,  and  general  accumulation 
of  fluid.  These  prominent  features  from  the  clinical  standpoint  read- 
ily separate  interstitial  and  parenchymatous  nephritis.  Pathologically, 
the  small,  tough,  granular  kidney  and  the  large,  soft,  pale,  and  smooth 
kidney  are  perfectly  distinct. 

*  "  On  the  Use  of  the  Ophthalmoscope  in  Diseases  of  the  Nervous  System  and  of  the 
Kidneys,"  Dr.  T.  Clifford  AUbutt,  chapter  vii,  London  :  Macmillan  &  Co. 


460  DISEASES  OF   THE   KIDNEY. 

Treatment. — As  interstitial  nephritis  is  an  incurable  disorder  when 
the  proper  secreting  structure  of  the  organ  is  destroyed,  it  is  impor- 
tant to  arrest  the  initial  changes,  if  we  possess  the  means  of  so  doing. 
Those  cases  arising  from  syphilitic  infection,  or  from  plun^bic  or  other 
metallic  poisoning,  offer  the  best  prospect  of  cure,  if  the  proper  reme- 
dies are  applied.  It  is  in  the  cases  arising  from  these  causes,  probably, 
that  such  good  results  are  obtained  by  the  persistent  use  of  full  doses 
of  the  iodide  of  potassium.  The  author  has  observed  several  cases  in 
which  the  iodides  seemed  to  arrest  the  disease  permanently,  and  others 
in  which  the  corrosive  chloride,  administered  in  small  quantity  (one 
twentieth  of  a  grain)  for  a  lengthened  period,  effected  cures  under 
apparently  very  unpromising  circumstances.  Better  results  even,  the 
author  believes,  are  procured  from  the  careful  and  persistent  adminis- 
tration of  the  chloride  of  gold,  or  of  gold  and  sodium.  Similar  thera- 
peutical properties  are  possessed  by  arsenic.  In  sclerosis  of  the  liver,  as 
well  as  in  that  of  the  kidney,  we  find  that  arsenic  exercises  a  favorable 
influence  in  retarding  the  changes.  This  remedy  is  all  the  more  desir- 
able, since  it  has,  in  small  doses,  a  sedative  effect  on  the  stomach,  and 
promotes  appetite  and  digestion.  These  remedies,  intended  to  arrest 
the  hyperplasia  of  the  connective  tissue,  should  be  prescribed  with  a 
definite  relation  to  the  presumed  cause — iodide  of  potassium  and  bi- 
chloride of  mercury,  in  those  with  a  syiihilitic  history  ;  iodide  of  potas- 
sium, in  those  poisoned  by  lead  ;  and  chloride  of  gold  and  arsenic,  in 
those  cases  of  unknown  origin.  When  there  are  much  acidity,  flatulence, 
and  pain  after  food,  mineral  acids,  especially  the  muriatic,  taken  before 
meals  render  important  service.  Doubtless  the  uric-acid  diathesis  is 
a  very  influential  factor  in  the  development  of  the  disease,  and  hence 
those  remedies  which  lessen  its  formation  are  deserving  of  high  con- 
sideration. The  utility  of  the  mineral  acids  consists  in  preventing  the 
acid  fermentation  of  the  food  and  in  promoting  digestion,  so  that  the 
nitrogenous  constituents  are  better  prepared  for  assimilation.  For  the 
anaemia  present,  iron  is  generally  prescribed,  but  the  effects  are  iisually 
rather  disappointing.  The  most  useful  chalybeate  is  the  tincture  ferri 
acetata,  which  is  also  formed  extemporaneously  in  Basham's  mixture, 
composed  of  tinct.  ferri  chloridi,  liquor  ammonise  acetatis,  and  acetic 
acid.  If  iron  is  given  freely  and  for  a  long  time,  headache  and  a  dis- 
ordered stomach  will  require  its  discontinuance  ;  nevertheless,  the  occa- 
sional and  careful  use  of  iron  is  beneficial.  When  the  symptoms  of 
uraemia  come  on,  the  case  requires  most  careful  handling.  If  the  stom- 
ach and  intestines  are  yet  capable  of  good  work,  the  treatment  may  be 
more  direct  and  efficient  ;  but  if  the  severe,  even  uncontrollable  vomit- 
ing and  purging  occur,  so  often  present  as  a  part  of  the  uraemia,  the 
difficulties  of  the  management  are  greatly  enhanced.  In  the  former 
case,  active  purgatives,  as  elaterium,  croton-oil,  and  compound  jalap, 
jiowder,  procure  elimination  through  the  intestinal  canal,  and  are  of 


AMYLOID  KIDNEY.  401 

signal  service.  In  the  lattei'  case,  the  important  results  derived  from 
purgatives  are  precluded.  Diaphoretics,  as  the  vapor  or  hot-air  bath 
and  the  injection  subcutaneously  of  pilocarpine,  are  the  most  powerful 
means  of  relief.  Purgatives  and  the  vapor-bath,  or  pilocarpine,  will 
in  those  cases  of  acute  exacerbation  in  the  renal  trouble,  when  the 
patient  is  yet  in  good  condition,  relieve  the  symptoms  remarkably,  and 
subsequently  there  may  be  a  long  period  of  tolerable  health.  The 
convulsive  and  nervous  phenomena  of  uraemia  are  best  remedied  by 
the  means  for  procuring  elimination,  but,  if  the  symptoms  are  urgent, 
the  inhalation  of  amyl  nitrite,  chloroform,  and  ether  may  be  necessary. 
The  hypodermatic  injection  of  morphia  in  large  doses  has  been  showm 
by  Loomis,  of  New  York,  to  have  a  remai'kable  influence  on  the  con- 
vulsions of  uraemia ;  but  chloral  by  the  stomach  or  rectum  may  be 
better. 

The  nutrition  of  the  patient  is  of  the  first  consequence.  The  diet 
should  be  simple,  and  consist  of  milk,  eggs,  a  little  fresh  meat  (once  a 
day),  and  fruits,  if  diarrhoea  does  not  exist.  The  best  results  have  been 
obtained  from  an  exclusive  milk-diet ;  as  this  becomes  irksome,  intoler- 
able even,  the  plan  of  diet  just  suggested  is  best.  Malt  liquors,  spirits, 
and  wines  are  highly  objectionable,  especially  the  first  named.  The 
clothing  should  be  warm  ;  flannel  should  be  worn  by  day,  and  the  pa- 
tient should  sleep  between  blankets.  Whenever  his  means  will  permit, 
the  patient  should  seek  a  warm,  dry,  and  uniform  climate.  Recent 
observations  by  Drs.  Sparks  and  Bruce  in  respect  to  the  influence  of 
diet,  rest,  and  exercise,  on  the  excretion  of  albumen,  have  led  to  the 
following  results  :  the  amount  of  albumen  is  much  reduced  by  a  milk- 
diet  and  non-nitrogenous  food,  and  "  absolute  rest  remarkably  reduced 
the  amount  of  albumen."  * 

THE   AMYLOID   DISEASE   OF   THE   KIDNEYS. 

Definition. — By  the  term  amyloid  disease  is  meant  an  afi'ection 
characterized  by  the  deposit  of  amyloid  matter.  As  it  occurs  in  the 
kidneys,  this  disease  is  known  as  lardaceous  kidney,  xoaxy  kidney, 
because  of  the  supposed  resemblance  to  lard  and  wax  respectively. 
By  Dickinson  the  disease  is  distinguished  by  the  title  "  depurative 
infiltration." 

Causes. — The  chief  cause  is  suppuration,  especially  of  protracted 
suppuration  of  or  connected  with  the  cancellous  structure  of  bones,  or 
of  ulcerations  affecting  the  skin  and  mucous  membrane.  It  is  neces- 
sary that  the  suppuration  be  profuse  and  protracted,  but  it  is  not 
necessary  that  it  occur  in  bone  only.  But  suppuration  alone  is  not 
sufficient  to  cause  the  amyloid  deposit.  There  must  be  a  peculiarity 
of  constitution  precedent,  for,  of  all  exposed  to  this  destructive  malady 
*  "  Medico-Chirurgical  Transactions,"  18*79,  p.  254. 


462  DISEASES  or   THE   KIDXEY. 

by  suppuration,  but  a  small  number  actually  are  affected  by  amyloid 
change.  It  is  more  apt  to  occur  in  those  under  the  influence  of  chronic 
m^alarial  poisoning,  but  more  influential  diathetic  states  are  those  of 
syphilis,  scrofula,  tuberculosis,  and  cancer — especially  cancer.*  It  is 
impossible  to  indicate  in  the  present  state  of  knowledge  the  relation 
of  these  cachexise  to  amyloid  disease,  but  it  seems  pretty  clear  that 
more  or  less  protracted  suppuration  coincided  with  the  cachexia. 
According  to  Bartels,  ulcerations  of  the  intestines  are  more  certain 
than  ulcerations  of  any  other  mucous  membrane  to  induce  amyloid 
disease  ;  and,  further,  that  the  supjDurating  center  must  have  communi- 
cation with  air  to  possess  this  peculiar  property.  The  amyloid  depos- 
its are  not  limited  to  one  organ,  but  occur  in  the  liver,  spleen,  intesti- 
nal canal,  the  supra-renal  bodies,  the  lymphatic  glands,  the  thyroid 
gland,  and  the  kidneys. 

Pathological  Anatomy. — The  term  amyloid,  or  starch-like,  was 
originally  proposed  by  Yirchow,  because  of  the  reaction  under  iodine, 
and  the  characteristic  structure  remotely  resembling  starch.  The 
theory  of  Dickinson  that  this  substance  is  fibrin  deprived  of  its 
alkali,  which  has  been  eliminated  from  the  body  in  the  pus,  has  been 
completely  disproved  by  the  elaborate  investigations  of  ]Vlr.  George 
Budd.f  "The  cells  of  an  organ  affected  may  be  seen  to  become 
gradually  distended  with  a  translucent  deposit,  and  soon  an  accumu- 
lation of  a  similar  deposit  takes  place  in  the  intercellular  spaces  also." 
There  is  present  in  the  blood  in  the  normal  a  considerable  quantity  of 
substance,  nanied  by  Seegen  "  dystropodextrin  " — "  a  substance  which 
agrees  with  laxdacein  (amyloid  material)  in  its  most  specific  charac- 
teristic." To  account  for  lardaceous  disease,  then,  it  is  only  necessary 
to  suppose  that  this  dystropodextrin  becomes  insoluble,  and  is  precipi- 
tated and  deposited  in  the  tissues.  This  substance  reacts  to  iodine, 
just  as  the  amyloid  matter,  and  agrees  with  it  in  aU  other  particulars, 
so  that  this  theory  is  more  plausible  than  any  heretofore  proposed. 
When  the  amyloid  matter  is  deposited  in  the  kidneys  to  a  consider- 
able extent,  the  organs  are  larger  and  heavier  than  normal,  and  are 
also  very  firm  in  texture.  The  capsule,  which  is  very  thin,  is  easily 
detached,  and  the  surface  of  the  kidney  is  pale,  gray,  or  whitish,  and 
has  a  glistening,  even  a  polished,  appearance.  The  cortical  part  is 
broad,  but  pale  and  ansemic,  while  the  cones  are  dark  and  congested. 
On  microscopic  examination,  the  change  that  has  taken  place  in  the 
organ  is  found  to  have  occuiTed  along  the  renal  vessels  and  in  the  vas- 
cular tufts  of  the  glomeruli,  at  first  at  isolated  points,  and  subsequent- 
ly along  the  whole  extent  of  these  vessels.     As  the  morbid  process 

*  "  Transactions  of  the  Pathological  Society  "  of  London,  vol.  xxx,  p.  511 ;  paper  by 
Dr.  Dickinson,  and  discussion. 

f  London  "  Lancet,"  February  28  and  March  27,  1880  ;  "  Amyloid  Degeneration,"  by 
Georce  Budd,  Jr. 


AMYLOID   KIDNEY.  463 

extends,  the  afferent  and  effei-ent  vessels,  the  vasa  recta,  and  ulti- 
mately the  renal  epithelium  and  even  casts,  still  contained  within  the 
tubes,  are  seen  to  be  embraced  in  the  degeneration  or  deposition.  If 
a  thin  section  of  the  kidney  is  laid  on  a  white  plate  after  being  brushed 
over  with  the  iodine  solution  (iodine  and  iodide  of  potassium),  the 
branching  lines  and  points  of  reddish-brown  stand  out  prominently 
beside  the  pale  yellow  of  the  healthy  tissues.*  Besides  the  kidneys, 
other  organs  of  the  body  undergo  the  same  change,  but  the  kidneys 
may  be  affected  alone.  The  supra-renal  capsules,  the  liver,  spleen,  the 
intestinal  canal,  etc.,  are  similarly  affected.  When  an  organ  is  thus 
infiltrated  by  this  new  material,  its  proper  structure  undergoes  an 
atrophic  degeneration  by  pressure.  With  the  amyloid  change  may  be 
associated  interstitial  or  parenchymatous  nephritis,  especially  the  lat- 
ter. It  is  more  proper  to  say  that  during  the  progress  of  interstitial 
nephritis  the  amyloid  degeneration  comes  on  ;  hence  the  lardaceous  or 
amyloid  kidney  may  be  more  or  less  granular  and  contracted,  instead 
of  being  enlarged  and  smooth.  With  lardaceous  kidney  are  associated 
chronic  ulceration  of  the  lungs,  and  suppurating  cavities,  ulcerations 
of  the  intestines,  diseases  of  bones  and  joints,  syphilitic  lesions  of  the 
mucous  membrane,  external  integument,  and  scrofulous  abscesses. 

Symptoms. — As  amyloid  disease  of  the  kidney  arises  during  the 
course  of  some  chronic  wasting  malady,  its  onset  is  necessarily  ob- 
scured by  the' complexus  of  symptoms  already  prominent.  There  is, 
of  course,  a  marked  degree  of  anaemia  produced  by  prolonged  suppu- 
ration, and  by  amyloid  changes  in  other  organs  besides  the  kidney. 
The  urine  is,  as  a  rule,  increased  in  amount  and  may  be  considerably  so, 
especially  in  those  cases  complicated  by  interstitial  nephritis,  or  it  may 
be  considerably  diminished  in  quantity,  when  there  coexists  parenchym- 
atous nephritis.  But  in  genuine  amyloid  kidney  the  urine  is  increased, 
is  pale,  watery,  and  of  very  low  specific  gravity — 1002  not  unfrequent- 
ly — and  usually  under  1006.  When  associated  with  parenchymatous 
nephritis  the  specific  gravity  may  rise  to  1030,  or  when,  as  may  hap- 
pen, the  quantity  passed  is  very  low.  The  amount  of  urea  and  other 
solid  constituents  is  much  reduced  when  the  quantity  is  great,  and 
greater  when  the  quantity  of  urine  is  small.  The  amount  of  urea  ex- 
creted depends  on  two  factors  :  on  the  functional  activity  of  the  liver 
and  the  extent  of  disease  in  the  kidneys.  Albumen  is  always  present. 
At  times,  during  the  first  implication  of  the  kidneys  in  the  morbid  pro- 
cess, there  may  be  none,  and  when  present  the  quantity  is  sufficient  to 
impart  a  faint  cloudiness  merely,  but  it  becomes  permanent  as  a  con- 
stituent of  the  urine  during  the  height  of  the  disease,  unless  just  at  the 
close,  when  it  may  disappear  again.     The  urine  contains  so  little  else 

*  Safranine,  an  aniline  product,  is  said  to  be  an  admirable  test  for  amyloid  matter. 
Sections  are  immersed  in  a  very  dilute  watery  solution.  The  amyloid  matter  is  stained 
orange-yellow ;  the  rest  of  the  tissue,  rose. 


404 


DISEASES   OF   THE   KIDNEY. 


than  waffer  that  the  sediment  is  very  small  in  amount,  and  hence  it  re- 
quires a  good  deal  of  urine  to  collect  even  a  few  casts.  Only  the  hyaline 
casts  are  proper  to  this  disease  ;  they  are  perfectly  transparent,  homo- 
geneous, and  slender,  so  that  they  are  seen  only  by  careful  management 
of  the  light.  Large  granular  casts,  blood-corpuscles,  and  renal  epithe- 
lium may  be  present  in  considerable  quantity  when  parenchymatous 


Fig.  86. — A  Lorge  Hyaline  Cast  without,  and  Two  with  Epithelium.   "(Beale.) 


nephritis  is  a  complication.  The  casts  may  present  a  faintly  yellow 
and  highly  refracting  appearance  when  attacked  by  the  amyloid  change 
or  composed  of  the  amyloid  material. 

More  or  less  oedema  is  always  present,  but  general  dropsy  is  infre- 
quent. The  oedema  is  found  in  the  lower  extremities,  and  ascites  is 
usually  present,  and  disproportionate  to  the  quantity  of  fluid  elsewhere. 
This  is  doubtless  due  to  the  implication  of  the  liver  in  the  general 
morbid  process,  and  to  the  swelling  of  the  lymphatics  in  the  hilus  of 
the  liver,  compressing  the  vena  porta.  With  the  progress  of  the  dis- 
ease, there  are  necessarily  increasing  weakness  and  anaemia,  a  pecu- 
liar earthy  or  fawn  color  of  the  skin,  and  pigmentation  of  the  eyelids. 
The  exhaustion  of  the  vital  forces  is  greatly  hastened  by  the  occur- 
rence of  a  profuse,  watery,  and  uncontrollable  diarrhoea.  Vomiting  also 
occasionally  takes  place,  but  not  nearly  with  the  frequency  and  persist- 
ence of  the  diarrhoea. 

Course,  Duration,  and  Termination. — Amyloid  kidney  is  an  essen- 
tially chronic  malady,  but  its  fortunes  partake  of  the  changes  and 
progress  of  the  associated  malady.  Commencing  insidiously,  its  pres- 
ence is  recognized  only  when  an  increasing  urinary  discharge  calls 
attention  to  the  state  of  the  kidneys.  The  duration  of  the  disease  is 
largely  determined  by  the  suppurating  malady  causing  it ;  but,  when  the 


AMYLOID   KIDNEY.  4(]5 

amyloid  change  is  clearly  begun,  the  case  usually"  terminates  in  death 
in  a  few  months,  but  may  extend  to  years.  Uraemia,  as  manifest  in 
vomiting,  purging,  amaurosis,  partial  and  general  convulsions,  etc., 
does  not  occur  in  amyloid  disease,  unless  the  contracting  kidney  also 
develops,  or  there  is  a  sudden  appearance  of  parenchymatous  nephritis. 
Death  by  cerebral  haemorrhage  is  also  rare.  Hypertrophy  of  the 
heart  and  of  the  arterioles  does  not  take  place  in  this  fonn  of  kidney- 
disease.  The  termination  is  often  by  some  acute  inflammation,  as  pneu- 
monia, pleuritis,  or  purulent  peritonitis,  etc.  The  duration  will  neces- 
sarily be  much  influenced  by  the  occurrence  of  such  inflammation. 
Many  of  the  cases  terminate  by  exhaustion,  the  bodily  forces  being 
worn  out  by  the  protracted  suppuration  and  the  loss  of  albumen,  but 
especially  by  the  profuse  diarrhoea.  The  termination  may,  then,  be 
due  in  most  cases  to  lesions  of  other  organs.  The  question  of  recovery 
is  largely  that  of  the  associated  diseases.  The  data  do  not  yet  exist 
for  deciding  on  the  possibility  of  an  arrest  of  the  amyloid  change  in 
the  kidneys,  or  the  regression  of  deposits  already  made,  but  it  is  ex- 
tremely doubtful  whether  a  genuine  case  ever  terminates  in  recovery. 
In  a  reported  case  of  recovery  there  must  ever  remain  a  doubt  respect- 
ing the  accuracy  of  the  diagnosis. 

Diagnosis. — Amyloid  kidney  is  to  be  distinguished  from  paren- 
chymatous nephritis  and  interstitial  nephritis.  The  history  of  the  case 
is  here  highly  important,  especially  the  constant  relation  of  suppura- 
tion to  lardaceous  degeneration.  In  parenchymatous  nephritis  the 
urine  is  scanty,  high-colored,  of  high  specific  gravity,  and  deposits  an 
abundant  sediment,  containing  urates,  granular  casts,  tubular  epithe- 
lium, and  red-blood  globules  ;  in  amyloid  kidney  the  urine  is  abun- 
dant, pale,  of  low  specific  gravity,  deposits  very  little  sediment,  con- 
taining a  few  hyaline  casts  and  occasional  waxy  casts,  but  no  blood- 
corpuscles.  In  parenchymatous  nephritis,  dropsy  forms  quickly  and 
is  extensive  ;  in  amyloid  kidney,  the  effusion  is  slight  and  confined  to 
the  lower  extremities  and  to  the  peritoneal  cavity.  Amyloid  kidney 
is  distinguished  from  chronic  interstitial  nejjhritis  by  its  history  and 
association  with  suppuration  in  some  form,  and  with  the  evidences  of 
the  same  change  in  the  liver,  spleen,  and  intestinal  canal.  In  chronic 
interstitial  nephritis  the  symptoms  of  uraemia  are  very  pronounced  at 
some  period  ;  in  amyloid  kidney  these  symptoms  very  rarely  occur  at 
any  period. 

Treatment. — As  when  the  amyloid  deposits  have  taken  place  it 
seems  doubtful  if  their  removal  can  be  effected,  it  is  highly  important 
to  stop  all  sources  of  suppuration,  and  thus  prevent  the  deposition  of 
the  altered  fibrin.  Attention  should  be  directed  at  once  to  the  cure 
of  suppuration.  As  syphilis  and  the  suppuration  connected  with  it  are 
a  fruitful  source  of  mischief  in  this  direction,  this  malady  should  be 
efficiently  treated  and  cured,  and  all  cases  presenting  a  syphilitic  his- 


466  DISEASES   OF   THE   KIDXEY. 

tory  should  be  given  a  thorougli  course  of  the  iodide  of  potassium. 
Dickinson,  influenced  by  bis  theoretical  notions,  advises  the  internal 
use  of  the  potash  and  soda  salts,  supplying  artificially  the  alkali  which 
is  carried  off  in  the  pus,  while  the  fibrin  is  deprived  of  it.  He  at  the 
same  time  enjoins  the  free  use  of  eggs  and  milk,  to  supply  the  material 
lost  in  the  urine.  Iron,  cod-liver  oil,  and  a  generous  diet  are  demanded 
bv  the  condition  of  feebleness  and  anaemia.  The  exhausting  diarrhoea 
resists  all  means  of  treatment,  but  the  most  efficient  remedy,  according 
to  the  author's  experience,  is  Fowler's  solution  and  opium  tincture — 
three  drops  of  the  former  and  five  to  ten  of  the  latter,  three  or  four 
times  a  day. 

PYELITIS   AND   PTELONEPHRITIS. 

Definition. — Pyelitis  means  an  inflammation  of  the  pelvis  of  the 
kidney  ;  pyelonephritis  includes  i^yelitis  and  a  consecutive  or  simul- 
taneous suppurative  inflammation  of  the  kidneys.  They  are  here  con- 
sidered together  to  avoid  repetition,  and  because  of  their  frequent  as- 
sociation. 

Causes. — Probably  the  most  frequent  cause  of  pyelitis  is  the  exten- 
sion of  a  morbid  process  from  the  bladder  to  the  pelvis  of  the  kidney, 
by  the  ureter.  Catarrh  of  the  bladder  is  lighted  up  by  decomposition 
of  the  urine,  consequent  on  its  retention.  Whenever  an  obstacle  exists 
to  the  discharge  of  urine  from  the  bladder,  the  decomposition  ensues, 
the  urine  becomes  ammoniacal,  and  the  mucous  membrane  the  seat  of 
an  active  catarrhal  process.  Stricture  of  the  urethra,  enlarged  prostate, 
the  pressure  of  the  retroverted  uterus,  pregnant  utei-us,  or  of  a  pelvic 
tumor,  etc.,  act  by  hindering  the  urinary  discharge.  An  inflammation 
of  the  mucous  membrane  of  the  bladder,  due  to  gonorrhoea  or  other 
causes,  will  have  the  same  effect  by  causing  fermentation  of  the  urine. 
A  renal  calculus,  or  other  foreign  body,  present  in  the  pelvis  of  the 
kidney,  will  produce  catarrh  directly  by  irritating  the  mucous  mem- 
brane. Decomposition  of  the  urine  and  catarrh  extending  to  the  pelvis 
of  the  kidney  are  produced  by  paraplegia  :  the  bladder  being  para- 
lyzed, the  urine  is  retained  and  undergoes  putrefactive  fermentation. 
Diuretics  of  the  stimulant  kind,  as  copaiba,  turpentine,  and  cantharides, 
irritate  the  mucous  membrane  of  the  pelvis  of  the  kidney  in  passing 
through  these  organs.  Whenever  the  urine  decomposes,  vibrios  and 
bacteria  appear  in  it  in  immense  numbers  ;  the  urea  is  decomposed  and 
converted  into  the  carbonate  of  ammonia  ;  the  ammoniaco-magnesian 
phosphate  crystals  are  formed  in  great  quantity,  and  much  phosphate 
of  lime  is  separated  by  the  inflamed  mucous  membrane.  Pyelitis 
occurs  as  a  complication  in  various  infective  maladies — in  pysemia, 
puerperal  fever,  the  exanthemata,  etc.,  and  may  result  from  the  exten- 
sion of  a  neighboring  inflammation. 

Pathological  Anatomy. — The  changes  consist  in  the  ordinary  catar- 


PYELITIS.  467 

rhal  process,  the  mucosa  and  the  subraucosa  becoming  very  much  thick- 
ened in  old  cases,  the  vessels  varicose,  and  the  epithelium  niuch  changed 
by  the  proliferation  of  its  cells,  etc.  If  the  morbid  process  began  in 
the  bladder,  the  evidence  will  be  plain,  and  the  ureters  may  or  may  not 
be  affected  by  the  same  changes.  If  the  pyelitis  has  existed  for  some 
time,  the  kidneys  will  be  seen  to  be  in  a  process  of  suppuration — one 
or  both.  The  organ  is  more  or  less  enlarged,  is  deeply  congested  and 
reddish,  except  certain  spots  which  present  a  yellowish-white  color,  are 
wedge-shaped,  and  extend  through  the  cortex  to  the  apex  of  the  cone. 
On  section  these  patches  present  here  and  there  points  of  suppura- 
tion, are  swollen,  and  the  capsule  is  more  or  less  firmly  adherent  to 
them.  Suppuration  occurs  soon  all  along  the  extent  of  these  patches 
between  the  tubules.  Several  of  these  suppurating  patches  uniting, 
considerable  abscesses  form  ;  the  kidney  elements  are  disassociated, 
broken  up,  and  disappear  ;  and  from  the  cones  the  suppuration  pro- 
ceeding destroys  the  cortical  part,  and  ultimately  nothing  remains  but 
a  bag  of  pus  having  irregular  walls  marked  by  septa,  remains  of  caly- 
ces. It  seems  well  established  that  the  suppurative  inflammation  in 
the  kidneys  is  set  up  by  the  presence  of  bacterian  colonies  which  have 
migrated  from  the  inflamed  bladder.  With  high  powers  the  bacteria 
are  seen  arranged  in  parallel  lines  within  the  tubules.  They  appear  as 
minute,  globular,  highly  refracting  granules.  After  a  time  the  same 
bodies  are  seen  in  the  interstices  with  pus-corpuscles.  The  epithelium 
of  the  tubules  is  at  first  cloudy,  granular  from  fatty  degeneration,  but 
is  soon  destroyed,  the  whole  tube  being  filled  with  the  branching  fila- 
ments and  spores.  According  to  Klebs  (Ebstein),  the  inflammation 
proceeding  to  suppuration  is  excited  by  the  bacteria. 

Symptoms. — The  pyelitis  or  pyelonephritis  usually  encountered  is 
associated  with  chronic  cystitis,  ammoniacal  urine,  and  the  systemic 
state  produced  thereby.  When  due  to  the  presence  of  a  calculus  in 
the  pelvis  of  a  kidney,  the  symptoms  are  different  in  some  respects  ; 
hence  the  consideration  of  this  form  is  properly  postponed  to  the  sec- 
tion devoted  to  this  topic.  In  the  form  of  pyelitis  now  under  consid- 
eration, there  is  usually  more  or  less  irritability  of  the  bladder,  and  the 
urine  is  somewhat  more  abundant  than  normal.  The  urine  is  neutral 
or  alkaline  in  reaction,  milky  in  appearance  when  voided,  and  deposits 
a  copious  sediment,  whitish  or  faintly  yellowish-white  in  color.  The 
upper  layer  of  the  sediment  is  more  distinctly  whitish,  lighter,  and 
easily  disturbed  with  a  little  agitation,  whereas  the  bottom  layer  is 
heavier,  firmer,  and  unites  in  an  homogeneous  mass  which  sticks  closely 
to  the  vessel,  and  when  dislodged  rolls  out  in  a  tenacious,  gelatinous 
mass.  There  is  some  albumen  present,  but  not  more  than  is  proper  to 
pus.  On  microscopic  examination  there  are  present  mucus  and  pus- 
corpuscles,  chiefly  large  crystals  of  ammoniaco-magnesian  phosphate, 
and  by  no  means  frequently  epithelial  cells  from  the  pelvis  of  the  kid- 


468  DISEASES   OF   THE   KiDNEY. 

neys.  In  the  form  of  pyelitis  ai'ising  from  decomposing  urine  in  the 
bladder,  it  is  difficult  to  find  the  morphotic  elements  belonging  to 
the  kidney.  Besides  the  corpuscular  and  crystalline  forms  above  men- 
tioned, the  urine  contains  numberless  bacteria.     There  is  more  or  less 


Fig.  87. — Various  Forms  seen  in  Pyelitis. 

uneasiness  felt  posteriorly  just  under  the  false  ribs  and  extending 
downward  along  the  course  of  the  ureters,  and  the  usual  distress  aris- 
ing from  the  bladder  under  these  circumstances.  The  strength  de- 
clines, the  body  loses  flesh,  and  there  is  more  or  less  fever,  increasing 
toward  evening  and  with  a  morning  remission.  In  some  cases,  when 
pyelonephritis  is  developed  and  suppuration  is  going  on  in  the  kid- 
ney, the  fever  has  a  distinct  typhoid  type,  and  has  been  mistaken  for 
typhoid  ;  for  the  cerebral  disturbance — low-muttering  delirium — suh- 
sultus  tencUnmn,  and  stupor,  due  to  uraemia,  come  on  with  septicaBmic 
fever,  diarrhoea,  and  exhaustion,  due  to  suppuration.  In  still  a  third 
group  the  symptoms  are  those  of  pysemia.  Chills  occur  at  irregular 
intervals,  followed  by  very  high  temperature,  the  thermometer  indi- 
cating 104°,  105°,  or  106°  Fahr.,  and  then  a  profuse  sweat.  The  face 
has  an  earthy  hue,  the  countenance  is  anxious,  and  the  features  are  re- 
tracted and  pinched.  The  exhaustion  is  extreme,  the  pulse  feeble 
and  rapid.  During  the  febrile  exacerbation  there  is  usually  more  or 
less  delirium.  A  profuse  diarrhoea  and  complete  anorexia  hasten  the 
decline.  Secondary  abscesses  may  form  in  the  articulations,  or  in  the 
intermuscular  septa,  which  hasten  the  already  rapid  tendency  down- 
ward. 

Besides  the  usual  form  of  pyelitis  and  pyelonephritis  associated  with 
the  various  obstacles  to  the  outflow  of  urine,  and  with  ammoniacal  and 
decomposing  urine,  there  are  several  milder  forms.  Certain  renal  irri- 
tants, as  cantharides,  turpentine,  etc.,  and  exposure  of  the  body  to  cold 
while  in  a  warm  and  perspiring  state,  will  produce  a  simple,  primary, 
acute  pyelitis.  There  occurs  more  or  less  pain  in  the  region  of  the  kid- 
neys, extending  downward  along  the  course  of  the  ureters,  and  there 
may  be  slight  feverishness  toward  evening.  The  urine  is  acid  and 
somewhat  increased  in  quantity.  It  deposits  a  sediment  composed  of 
urates,  pus,  and  occasional  blood-corpuscles,  and  epithelium  from  the 
pelvis  of  the  kidney.  Pyelitis  also  occurs  in  childbed.  Then  it  begins 
with  chill,  followed  by  fever,  and  pain  in  the  lumbar  region.  The  pain 
may  have  a  very  acute  character,  and,  shooting  down  along  the  ureters 


RENAL   CALCULI.  469 

into  the  bladder,  seem  like  nephntic  colic.  The  urine  is  little  changed 
from  norn\al,  but  it  contains  some  pus  and  cells  of  renal  epithelium. 

Course,  Duration,  and  Termination. — The  simple  cases  of  pyelitis 
terminate  in  recovery  in  from  one  to  two  weeks.  Those  occurring  in 
childbed,  or  in  the  course  of  typhoid,  puerperal,  or  other  fevers,  ter- 
minate with  the  associated  malady.  Suppurative  pyelitis  and  pye- 
lonephritis have  a  variable  duration,  and  may  continue  for  months, 
even  years.  The  progress  is,  of  course,  more  rapid  when  the  kidney 
is  suppurating.  When  uraemic  symptoms  occur,  the  duration  of  the 
case  is  measured  by  weeks,  and  but  one  termination  is  possible. 

Diagnosis. — In  the  most  common  form  the  diagnosis  is  often  merely 
conjectural,  for  the  muco-pus  is  so  abundant  that  it  is  extremely  diffi- 
cult to  find  the  characteristic  forms  from  the  pelvis.  When  ursemic 
symptoms  finally  come  on,  there  can  be  doubt  no  longer.  In  the  simple 
cases  the  diagnosis  must  rest  on  the  association  of  pain,  with  altered 
urinary  secretion,  the  epithelium  of  the  pelvis  of  the  kidney  being 
present. 

Treatment. — In  the  simple  cases  mere  dilution  of  the  urine  affords 
relief.  If  the  urine  is  acid,  a  potash  salt — liq.  potassii  citratis — should 
be  administered  freely.  In  the  cases  of  pyelitis  associated  with  ammo- 
niacal  urine,  benzoic  acid  is  extremely  serviceable.  Gallic  acid,  pass- 
ing through  the  kidneys  unchanged,  has  a  local  effect  of  a  very  useful 
kind.  Excellent  results  have  been  obtained  from  the  persistent  use  of 
eucalyptol,  or  fluid  extract  of  eucalyptus.  The  oils  of  turpentine,  co- 
paiba,  and  cubeb  have  a  good  effect  in  changing  the  character  of  the 
mucous  membrane  and  limiting  the  formation  of  pus  ;  but  thej^  must 
be  given  in  small  doses.  Quinine  has  a  high  degree  of  utility — to  keep 
down  the  abnormal  temperature,  to  support  the  powers  of  life,  and  to 
check  pus-forming.  It  is  important  throughout  to  keep  up  the  strength 
by  suitable  aliment. 

RENAL   CALCULI— NEPHROLITHIASIS. 

Definition. — Renal  calculi  are  concretions  formed  by  precipitation 
of  certain  substances  from  the  urine  about  some  body  or  material  act- 
ing as  a  nucleus. 

Causes. — Calculi  occur  at  all  ages,  and  are  very  frequent  in  chil- 
dren before  the  fifth  year,  and  from  five  to  fifteen.  Males  are  much 
more  liable  to  them  than  females.  A  sedentary  life  and  indulgence 
in  a  highly  nitrogenized  diet  are  circumstances  favoring  the  occurrence 
of  the  uric-acid  diathesis.  Certain  districts  of  country  seem  pecu- 
liarly disposing,  the  character  of  the  drinking-water  being  held  respon- 
sible, especially  the  lime  present,  but  this  explanation  of  the  fact  is 
wholly  untenable.  A  special  susceptibility  exists  in  certain  families,* 
*  London  "Lancet,"  December  5,  1874. 


470  DISEASES   OF   THE   KIDNEY. 

various  members  of  whicli  may  be  attacked,  while  other  families  living 
under  the  same  conditions  are  unaffected. 

Pathogeny.  —  The  researches  of  Dr.  H.  Vandyke  Carter,  Ord,* 
Beale,  and  others  have  demonstrated  the  importance  of  mucus  in  de- 
termining the  precipitation  of  the  calculous  ingredients  of  the  urine. 
Calculi  are  of  all  sizes — from  microscopic  bodies  up  to  a  concretion  fill- 
ing the  pelvis  of  the  kidney.  Beale  f  has  shown  the  importance  of 
microscopic  calculi  present  in  the  urine,  as  indicating  similar  bodies  of 
larger  size  in  tne  pelvis.  In  the  kidneys  there  may  be  an  infinitude  of 
calculi — from  mere  grains  of  sand  to  concretions  of  considerable  size. 
Uric-acid  infarctions,  triple  phosphate-  and  carbonate- of -lime  infarc- 
tions, are  found  in  the  straight  tubes  of  the  pyramids  in  infants,  and 
in  old  men,  especially  those  affected  with  the  gouty  diathesis.  Cal- 
culi of  uric  acid  are  more  frequent  than  any  other  constituent,  for, 
although  this  substance  exists  in  small  quantity,  it  is  very  slightly 
soluble.  Ord  shows  that  uric  acid,  crystallizing  in  the  presence  of  col- 
loids (albumen,  mucus,  etc.),  tends  to  assume  a  spheroidal  form,  and 
Carter  that  a  bit  of  mucus  is  the  nucleus  about  which  the  crystalliza- 
tion takes  place.  These  calculi  are  made  up  of  concentric  layers,  and 
may  be  comjDosed  wholly  of  uric  acid,  or  of  alternate  layers  of  uric 
acid  and  oxalate  of  lime.  Similar  modifications  are  impressed  on  oxa- 
late of  lime,  but  while  they  tend  to  assume  the  spheriodal  form  in  the 
presence  of  mucus  they  also  crystallize  in  octohedra.  The  uric-acid 
calculi  are  grayish-red  or  reddish-brown,  smooth,  hard,  and  having  a 
specific  gravity  of  1'5.  The  pure  oxalate-of-lime  calculi  are  very  rare, 
are  very  hard  in  texture,  rough  on  the  exterior,  of  a  dark-brownish 
color.  The  oxalate  of  lime  with  a  nucleus  of  uric  acid  are  much  more 
common  than  the  pure  oxalate.  Calculi  of  cystine  are  still  more  rare 
than  those  of  oxalate  of  lime  ;  they  are  comparatively  soft,  and  have 
a  dull-yellow  or  amber  color.  Phosphatic,  next  to  uric,  are  the  most 
frequently  encountered  calculi.  They  are  very  light,  friable,  of  a  dull 
or  grayish-white,  or  bright  white,  rough,  and  sometimes  polished. 
The  phosphatic  deposit,  consisting  of  phosphate  of  lime  and  the  am- 
moniaco-magnesian  phosphate,  often  forms  about  a  uric-acid  calcu- 
lus which  has  been  present  for  some  time.  This  deposition  of  the 
phosphates  may  be  expected  to  take  place  on  a  uric-acid  calculus 
which  has  been  long  present  in  the  pelvis  of  the  kidney,  if  the  urine 
becomes  alkaline.  The  stones  may  be  in  one,  but  occasionally  they 
are  found  in  both  kidneys.  In  the  cases  which  have  fallen  under  my 
observation,  two  thirds  were  in  the  left  kidney.  The  results  of  the 
presence  of  concretions  differ  according  to  their  situation  :  in  the 
tubules,  as  infarctions,  they  excite  inflammation  of  the  liver  ;  in  the 
pelvis  they  cause  pyelitis.       Gouty  kidney  is    a  result  of   the  uric- 

*  Beale  on  "  Urinarj'  Deposits."  f  Ibid.,  March  13,  1875. 


REXAL   CALCULI.  47^ 

acid  diathesis,  and  deposits  of  this  substance  take  place  in  the  pyra- 
mids and  the  cortex,  parenchymatous  and  interstitial  nephritis  de- 
velop, and  the  organs  ultimately  become  granular.  When  nephro- 
pyelitis  is  fully  developed,  extension  of  the  morbid  process  to  the 
kidney  proper  takes  place.  When  pyelitis  is  lighted  up,  the  mucous 
membrane  becomes  intensely  injected,  and  a  quantity  of  muco-pus, 
proliferating  epithelium,  and  young  cells,  form  a  yellowish,  rather  thick, 
purif  orm  fluid.  If  a  concretion  is  not  too  large,  it  will  be  washed  down 
into  the  bladder,  with  the  phenomena  of  nephritic  colic.  Successive 
calculi  passing,  the  ureter  yields  and  dilates,  and,  as  these  concretions,  in 
passing,  excite  inflammation,  the  walls  of  the  ureters  become  thickened. 
An  attack  of  inflammation  may  close  the  canal  entirely,  or  a  ureter 
may  be  closed  by  an  impacted  calculus.  In  either  case  the  contents  of 
the  pelvis  accumulate,  the  proper  structure  of  the  kidney  undergoes 
atrophy,  and  after  a  time  only  a  membranous  sac  filled  with  fluid  and 
concretions  remains.  The  ichorous  contents  may  ulcerate  through, 
form  an  abscess  of  large  dimensions,  which  may  make  its  way  exter- 
nally, discharging  in  the  lumbar  region,  or,  dissecting  downward,  may 
point  underneath  Poupart's  ligament,  or  enter  the  colon,  etc. 

Symptoms. — A  calculus  may  remain  in  the  pelvis  of  a  kidney  for  a 
long  time — during  many  years — it  is  probable,  without  giving  rise  to 
any  disturbance.  Usually,  very  distinct  symptoms  are  occasioned,  and 
serious  results  grow  out  of  them.  A  calculus  causes  very  violent 
symptoms  when  washed  into  the  ureter.  Usually,  an  attack  of  ne- 
phritic colic  occurs  suddenly.  Without  any  warning,  an  atrocious  pain 
strikes  the  lumbar  region,  passes  downward  along  the  course  of  the 
ureter  into  the  groin,  and  radiates  thence  upward  into  the  shoulder- 
blade  and  through  the  abdomen.  Pains  occur  in  the  corresponding 
testis,  which  is  retracted  close  up  to  the  external  ring,  and  more  or 
less  pain,  sometimes  very  acute  pain,  is  felt  in  the  glans  penis.  So 
severe  is  the  pain  that  the  most  self -controlled  person  cries  out  with 
the  agony,  rolls  from  side  to  side,  or  rushes  up  and  down  the  room 
seeking  for  some  alleviation  in  incessant  motion.  The  face  is  pale  and 
torn  with  agony,  the  features  are  pinched,  the  body  is  cold  and  covered 
with  a  cold  sweat.  The  thigh  of  the  affected  side  is  benumbed,  and 
sometimes  the  whole  of  the  corresponding  limb.  The  patient  may 
faint,  or  pass  into  unconsciousness  with  a  general  convulsion.  The 
stomach  participates  in  the  disturbance  with  nausea,  or  with  severe 
vomiting.  The  bladder  is  very  irritable,  and  frequent  attempts  at 
micturition  are  made,  but,  with  much  burning  pain  and  straining,  only 
a  few  drops  are  passed.  The  urine  is  dark,  and  usually  contains  blood, 
but  it  may  be  perfectly  normal,  for,  as  but  one  ureter  is  involved  at  one 
time,  the  urine  from  the  unaffected  kidney  may  pass  without  admix- 
ture. The  urine  may  be  not  only  dark  and  bloody,  but  it  may  contain 
pus.     There  may  be  complete  anuria  from  blocking  of  both  ureters, 


472 


DISEASES   OF  THE   KIDNEY. 


but  usually  the  calculi  do  not  fit  accurately,  and  some  urine  escapes 
alongside  them.  If  anuria  is  the  result,  and  the  obstacle  is  not  re- 
moved, death  in  coma  and  convulsions  is  inevitable.  The  paroxysm, 
after  some  minutes  or  hours,  usually  terminates  suddenly  by  the  escape 
of  the  stone  into  the  bladder.  The  urine  accumulating  behind  the  stone 
forces  it  onward  with  increasing  agony,  until,  at  last  dropping  into  the 
bladder,  the  horrible  pain  ceases,  the  patient  utters  a  sigh  of  relief,  and 
falling  on  the  bed  exhausted  is  soon  fast  asleep.     The  attacks  do  not 


No.  1. 


Fig.  38.— Various  Crystalline  Forms. 
No.  1.— Uric  Acid.  No.  2.— Urate  of  Soda. 

No.  8.— Cystine.  No.  4.— Oxalate  of  Lime. 

No.  5.— Dumb-bell  Oxalate  of  Lime. 

always  come  on  abruptly.  There  may  be  experienced  some  deep-seated 
soreness  in  the  lumbar  region,  then  a  quick  movement  as  in  kicking, 
sneezing,  coughing,  etc.,  may  give  rise  to  a  sudden  increase  of  the  sore- 
ness, soon  developing  into  acute  pain.     Whether  the  onset  be  sudden 


RENAL   CALCULI.  473 

or  gradual,  the  attacks  are  not  of  equal  severity.  The  difference  we 
may  suppose  to  be  due  to  the  varying  sizes  of  the  calculi.  If  a  calculus 
become  impacted,  it  will  ulcerate  through  and  give  rise  to  fatal  perito- 
nitis. In  a  few  cases  the  calculus  has  occupied  a  number  of  days  in 
making  the  journey  through  the  ureter,  the  most  severe  suffering,  as  is 
usual,  occurring  at  last,  owing  to  the  increasing  narrowness  of  the  lower 
ureter.  If  repeated  attacks  occur,  the  rule  is  that  the  succeeding  ones 
are  milder,  but  this  depends  upon  the  size  of  the  calculi.  Gravel  and 
sand  may  occasion  no  distress  at  all,  or,  at  most,  some  little  burning  at 
micturition.  A  calculus  too  large  to  escape  through  the  meatus  uri- 
narius  may  pass  through  the  ureter  without  causing  recognizable  dis- 
turbances. 

If  the  calculi  are  retained  in  the  pelvis  of  the  kidney,  pyelitis  is,  as 
a  rule,  gradually  developed.  The  urine  ultimately  becomes  milky  from 
the  presence  of  muco-pus,  but  there  is  a  long  period  from  the  first 
appearance  of  a  slight  sediment  to  the  milky -white  appearance  on  emis- 
sion. During  this  intervening  time  there  is  a  favorable  opportunity 
for  diagnosticating  the  composition  of  the  calculus,  following  the 
method  of  Beale,  who  has  shown  that,  if  calculi  are  contained  in  the 
pelvis  of  the  kidney,  identical  microscopical  forms  may  be  recognized  in 
ithe  sediment.  The  author  has  confirmed  this  observation  of  Beale,  and 
has  had  in  his  own  cases  some  remarkable  examples  of  the  utility  of 
the  method.  Of  course,  when  calculi  of  a  size  to  be  recognized  by  the 
naked  eye  pass,  there  can  be  no  difiiculty  in  accounting  for  the  occur- 
rence of  symptoms  indicating  the  presence  of  a  renal  calculus.  Besides 
the  knowledge  gained  by  a  study  of  the  urine,  there  are  other  sources 
of  information.  Patients  affected  with  a  calculus  suffer  with  pain  ex- 
tending along  the  ureter  upward  into  the  lumbar  region  and  to  the 
spine.  This  pain  is  also  a  feeling  of  soreness  and  heaviness,  which  is  not 
removed  by  change  of  position,  and,  although  alleviated  by  lying  down 
at  night,  becomes  so  irksome  toward  morning  as  to  compel  the  patient  to 
rise,  or  to  make  incessant  changes  of  position.  More  or  less  frequent  at- 
tacks of  colic  are  produced  by  the  passage  of  plugs  of  mucus  or  shreds 
of  tissue,  but  they  are  not  accompanied  by  the  intense  suffering  pro- 
duced by  calculi.  If  the  ureter  becomes  obstructed,  as  may  happen, 
the  pus  and  the  urine,  so  long  as  the  kidney  continues  to  functionate, 
will  accumulate,  causing  the  condition  of  hydro-  or  pyonephrosis — fhe 
latter  when  there  exists  a  pyelitis.  The  gradual  accumulation  of  pus 
and  the  disintegration  of  the  kidney  substance  will  result  in  the  forma- 
tion of  a  sac  with  thick  walls,  presenting  evidences  of  renal  structure 
only  on  careful  inspection.  A  tumor  will  form  of  considerable  volume, 
projecting  downward  from  the  hypochondrium.  It  may  be  somewhat 
nodular,  irregular,  but  is  more  frequently  smooth  and  globular — the 
outline  and  shape  being  determined  by  the  degree  of  accumulation  ; 
hence  the  tumor  is  the  more  globular  and  less  nodular  the  more  an- 


4.74  DISEASES   OF   THE   KIDNEY. 

cient.  The  tumor  may  attain  to  very  large  size  ;  in  a  case  in  the 
author's  charge,  it  was  as  large  as  a  child's  head.  The  sac  may  yield 
and  the  contents  escape  into  the  peritoneal  cavity,  or  a  communication 
may  be  established  with  the  colon  or  stomach,  or  discharging  posteri- 
orly may  open  a  fistulous  communication  in  the  lumbar  region,  or  dis- 
secting downward  along  the  course  of  the  psoas  muscle  may  point 
under  Poupart's  ligament.  The  calculus  may  be  discharged  by  any  of 
these  channels.  When  the  ureter  is  closed,  the  urine,  which  before  was 
full  of  pus,  now  appears  clear  again.  An  obstruction  of  the  ureter 
may  be  temporary,  and  the  urine  after  a  short  period  of  freedom  from 
pus  may  become  loaded  with  it  again.  When  the  obstruction  yields, 
a  sudden  gush  of  purulent  urine  and  debris  will  cause  more  or  less 
pain  or  colic  ;  indeed,  the  attack  may  have  all  the  characteristics  of  a- 
severe  nephritic  colic. 

Course,  Duration,  and  Termination.  —  Nephrolithiasis  develops 
slowly,  is  very  chronic  in  its  course,  and  variable  in  the  results.  The 
exceptions  to  this  statement  consist  of  those  cases  which  terminate 
suddenly  by  rupture  of  the  ureter  and  peritonitis,  and  the  very  rare 
examples  of  septicaemia  or  pyaemia  occurring  with  the  beginning  sup- 
puration, or  of  uraemia  from  the  simultaneous  blocking  of  both  ureters. 
Renal  sand  and  small  concretions  may,  after  a  variable  period  of  de- 
tention, pass  down  the  ureter  and  be  discharged  with  the  urine.  Often 
concretions  of  considerable  size,  too  large  to  pass  the  meatus  urinari us, 
are  thus  discharged,  all  symptoms  ceasing  when  the  source  of  irritation 
is  removed.  Recovery  has  ensued  also  by  the  discharge  of  the  con- 
cretion through  a  fistulous  communication  externally,  the  kidney  under- 
going atrophy,  the  sac  closing,  and  the  formation  of  pus  ceasing.  As 
one  kidney  may  perform  the  duty  of  both,  a  cure  effected  in  this  way 
may  be  genuine.  Death  may  occur  from  exhaustion,  or  amyloid  de- 
generation may  be  the  result  of  the  protracted  suppuration  ;  pyaemia, 
or  some  intercurrent  malady,  may  quickly  terminate  life  in  a  portion 
of  the  cases. 

Diagnosis. — Renal  colic  may  be  confounded  with  biliary  colic.  The 
two  affections  are  frequently  associated.  They  are  distinguished  by 
the  situation  of  the  point  of  maximum  pain,  and  by  the  sequelae — 
hepatic  colic  followed  by  jaundice  and  pasty  stools,  renal  colic  by  ex- 
cessively irritable  bladder  and  bloody  urine.  Is  the  calculus  present 
uric  or  phosphatic  ?  The  preponderance  of  numbers  is  a  presumption 
in  favor  of  uric  acid.  But  the  determination  is  made  by  an  examina- 
tion of  the  sand,  gravel,  or  microscopic  calculi.  A  uric-acid  calculus, 
long  present  in  a  suppurating  pelvis  of  the  kidney,  w^ill  become  more 
or  less  deeply  incrusted  with  phosphatic  material,  and  the  urine  will 
contain  phosphate  crystals.  When  a  tumor  exists,  the  kidney  affected 
is  revealed.  That  one  and  not  both  kidneys  is  the  seat  of  disease 
may  be  determined  by  the  passage  of  perfectly  normal  urine  when 


RENAL   CALCULI.  475 

an  obstruction,  either  temporary  or  permanent,  prevents  the  escape  of 
pus. 

Treatment. — As  the  attack  of  renal  colic  requires  the  most  power- 
ful anodynes,  morphia  hypodermatically  should  be  employed  at  once. 
As  the  stomach  is  highly  irritable,  it  is  useless  to  give  medicines  by 
the  mouth  for  this  purpose.  Enemata  of  laudanum  act  efficiently  if 
sufficient  time  be  given  them.  The  inhalation  of  ether  may  be  prac- 
ticed until  more  pei'manent  relief  can  be  given.  The  warm  bath  is  ser- 
viceable by  inducing  relaxation.  If  gravel  or  sand  of  uric  acid  is  pres- 
ent, its  solution  and  excretion  should  be  effected  as  speedily  as  possible. 
The  urine  should  be  alkalinized  by  the  free  use  of  the  potash  and  lithia 
salts ;  soda  must  be  avoided,  as  the  urate  of  soda  is  not  readily  solu- 
ble. Probably  the  best  preparation  is  the  officinal  liquor  potassii  citra- 
tis,  of  which  a  tablespoonful  may  be  taken  every  three  hours.  Recently 
the  borocitrate  of  magnesium  and  the  benzoate  of  lithium  *  have  been 
used  successfully,  both  of  these  agents  having  remarkable  solvent  ef- 
fects on  uric-acid  calculus.  The  experiments  of  Roberts,f  however, 
seem  conclusive  as  to  the  solvent  action  of  the  potash  salts  ;  these  fail- 
ing, the  borates  and  benzoates  may  be  tried.  Nothing  can  be  accom- 
plished by  spasmodic  efforts.  The  solvent  action  must  be  maintained 
without  intermission  for  a  long  period.  Should  the  protracted  exist- 
ence of  a  uric-acid  calculus,  with  pyonephritis  and  alkaline  urine,  render 
it  probable  that  an  incrustation  of  phosphates  has  occurred,  the  benzo- 
ate of  ammonia  should  be  prescribed,  as  the  most  certain  means  of 
bringing  about  an  acid  condition  of  the  urine.  If  the  calculus  is  phos- 
phatic,  the  same  procedure  is  proper  to  produce  and  maintain  an  acid 
state  of  the  urine  until  the  phosphatic  incrustation  or  the  phosphatic 
calculus  is  dissolved.  When  this  is  accomplished,  the  method  above 
mentioned  must  now  be  pursued.  In  the  treatment  of  pyelitis  those 
remedies  are  to  be  employed  which  are  eliminated  by  the  kidneys  and 
exert  a  local  action — copaiba,  cubebs,  santalura,  juniper,  erigeron,  euca- 
lyptol,  turpentine,  etc.  These  must  be  used  with  caution,  because  of 
their  irritant  effects  on  the  kidneys.  Probably  the  most  generally  use- 
ful, and  at  the  same  time  safe,  is  eucalyptol.  This  should  be  admin- 
istered in  small  doses,  relying  upon  the  results  of  a  slight  impression 
maintained  for  a  long  time.  Any  of  the  members  of  this  group  may 
be  employed  instead  of  eucalyptol,  under  the  same  limitations.  The 
so-called  diuretics — scoparius,  squill,  buchu,  pareira,  etc. — have  also 
been  recommended,  but  they  are  less  effective  than  the  oils.  Canthari- 
des  tincture  has  been  prescribed  in  small  doses  with  advantage  in  pye- 
litis. The  free  use  of  skimmed  milk,  and  buttermilk  when  it  is  grate- 
ful or  preferred,  is  decidedly  beneficial.  When  the  existence  of  the 
tumor  can  be  made  out  clearly,  it  should  be  evacuated  posteriorly  by 

*  "Bulletin  General  de  Therapeutiquc,"  January  30,  1880. 
f  "Urinary  and  Renal  Diseases,"  op.  cit. 


476  DISEASES   OF   THE   KIDNEY. 

the  aspirator.  If  the  calculus  can » be  reached,  a  free  opening  should 
be  made  and  a  drainage-tube  inserted.  The  sac  can  then  be  kept 
thoroughly  empty,  clean,  and  in  the  most  favorable  condition  for 
shrinking  and  ultimate  closure.  Recovery  has  ensued.  In  a  case  of 
the  author's  in  which  the  sac  was  opened  from  behind,  the  calculus  was 
removed  and  free  drainage  secured,  but  the  patient  was  exhausted  by 
protracted  suppuration. 

HYDRONEPHROSIS— DROPSY  OP  THE  KIDNEY. 

Definition. — Hydronephrosis  consists  in  an  accumulation  of  the 
urine  and  dilatation  of  the  pelvis  and  calyces,  with  progressive  atrophy 
of  the  renal  structure. 

Causes. — Hydronephrosis  may  be  congenital  or  acquired.  When 
congenital  it  is  due  to  some  anatomical  anomaly.  It  is  more  common 
in  women  than  in  men,  because  of  the  functions  peculiar  to  the 
former.  Obstruction  of  the  ureter  is  the  usual  cause  ;  the  nature  of 
the  obstruction  may  differ  greatly.  The  ureter  may  be  blocked  by  a 
calculus,  by  inflammation  and  adhesion  of  the  mucous  surfaces,  by 
constriction  of  a  band  of  lymph,  by  pressure  of  a  tumor,  by  the  dis- 
placed uterus,  etc.  When  an  obstruction  is  caused  by  the  impaction 
of  a  calculus,  it  is  usually  found  in  situ ;  but  not  invariably  so,  for 
sometimes  the  calculus  crumbles  and  disappears. 

Patholog'ical  Anatomy. — The  dilatation  will  involve  the  more  of 
the  ureter,  the  lower  down  the  obstruction  is  placed.  The  degree  of 
damage  done  to  the  kidney  will,  of  course,  be  determined  by  the 
amount  of  fluid.  In  an  extreme  case  the  kidney-structure  will  have 
disappeared,  nothing  remaining  but  a  huge  membranous  bag,  the 
ureters  distended  into  somewhat  tortuous  cylinders  the  size  of  a  small 
intestine,  and  with  more  or  less  thickened  walls.  When  the  accu- 
Uo.  2:  mulation    is  small    in    amount,   the  pelvis 

is  somewhat  dilated,  the  calyces  also,  and 
the  papillae  are  flattened.  As  the  fluid  in- 
creases, there  will  be  increasing  atrophy  of 
the  kidney,  the  medullary  portion  first  dis- 
appearing, and  ultimately  the  cortical  part. 
No.?Ureten^^o!'2!u?ethra.  The  sac  may  be  of  enormous  dimensions, 
filling  half  the  abdominal  cavity,  displacing 
organs  and  contracting  adhesions  to  neighboring  parts.  The  colon 
may  be  compressed  and  adherent  very  closely  to  the  walls  of  the  sac. 
The  original  capsule  of  the  kidney,  thickened  by  new  connective  tis- 
sue, forms  the  walls  of  the  sac,  the  lobulated  appearance  being  due  to 
the  internal  septa.  The  fluid  in  the  sac  is  modified  urine — it  is  pale, 
of  low  specific  gravity,  alkaline  in  reaction,  and  contains  urea,  uric 
acid,  urates,  etc.,  or  it  may  be  brownish  in  color  from  the  presence  of 


HYDRONEPHROSIS.  477 

blood,  or  yellowish  and  turbid  from  the  presence  of  pus  (pyonephritis). 
The  fluid  usually  contains  traces  of  albumen,  which  may  be  consid- 
erable if  blood  is  present,  and  more  or  less  epithelium  may  also  be 
occasionally  found.  The  accumulation  is  usually  limited  to  one  kid- 
ney, the  other  being  enlarged  to  compensate  for  the  absence  of  its 
fellow. 

Symptoms. — It  is  an  extremely  rare  event  for  both  kidneys  to  be 
affected,  and  hence  uraemia  is  not  a  common,  is  indeed  a  rare  symp- 
tom. The  accumulation  occurs  silently,  and  hence  it  is  the  formation 
of  a  fluctuating  tumor  that  first  attracts  attention.  The  size  depends 
somewhat  on  the  age  of  the  growth  ;  it  may  have  the  dimensions  of  a 
child's  head.  In  growing,  adhesions  form,  which  give  rise  to  acute, 
stabbing  pains  at  the  time  of  their  formation.  When  the  tumor  at- 
tains suflicient  volume  to  displace  or  compress  the  neighboring  organs, 
corresponding  disturbances  are  occasioned.  If  the  colon  is  compressed, 
great  accumulation  of  fseces  will  take  place  above  that  point ;  if  the 
diaphragm  is  pushed  up,  dyspnoea  will  result ;  if  the  stomach  is  pressed 
on,  there  will  be  nausea  and  vomiting  ;  if  the  tumor  rests  on  the  ab- 
dominal aorta,  a  pulsation  will  be  communicated  to  it.  It  is  important 
to  note  that  the  colon  in  hydronephrosis  of  the  left  side  may  lie  in 
front  of  the  tumor.  The  author  saw  a  surgeon  pass  a  trocar  through 
the  large  intestine  to  reach  the  sac.  The  tumor  has  usually  some 
firmness,  does  not  fluctuate  very  easily,  although  distinctly,  and  is  not 
movable.  It  may  be  handled  freely  without  pain,  as  a  rule,  unless 
adhesions  have  recently  formed,  when  it  will  be  tender. 

Course,  Duration,  and  Termination.— The  course  of  hydronephrosis 
is  chronic,  the  onset  obscure,  the  formation  of  a  tumor  slow,  and  the 
final  disposition  of  the  sac  a  tedious  process.  Years  will  be  occupied 
in  the  development  of  these  several  stages.  A  genuine  cure  is  rarely 
effected.  It  may  happen  that  an  obstruction  within  the  ureter  yields 
and  the  water  flows  away,  but  this  is  very  uncommon.  If  the  accumu- 
lation be  due  to  pressure  of  a  displaced  uterus,  a  cure  is  readily  effect- 
ed by  correcting  the  displacement.  When  not  remediable,  the  ter- 
mination is  ultimately  fatal,  death  being  due  to  the  complications 
arising  from  the  pressure  on  organs,  or,  the  sac  giving  way,  general 
peritonitis  is  the  result. 

Diagnosis. — Hydronephrosis  is  most  frequently  confounded  with 
ovarian  tumor.  The  former  develops  from  above,  the  latter  from 
below.  The  withdrawal  and  examination  of  the  fluid  are  usually  ne- 
cessary to  come  to  right  conclusions.  The  fluid  of  hydronephrosis  is 
usually  watery  and  contains  urea,  uric  acid,  and  epithelium  ;  the  fluid 
of  ovarian  disease  contains  the  compound,  granular,  many-nucleated 
corpuscles,  is  dark  in  color,  and  somewhat  gelatinous  in  consistence. 
Hydronephrosis  may  be  confounded  with  ascites  when  both  kidneys 
are  affected.    They  are  to  be  distinguished  by  the  changes  in  the  posi- 


478  DISEASES   OF   THE   KIDNEY. 

tion  of  the  dullness,  on  changes  of  posture  in  cases  of  ascites,  which 
do  not  occur  in  hydronephrosis.  In  the  beginning  of  ascites,  if  the 
patient  lies  recumbent,  the  dullness  is  in  the  flank  ;  in  hydronephrosis 
the  dullness  is  at  the  site  of  the  tumor,  and  does  not  change  its 
jDOsition. 

Treatment. — The  sac  has  been  emptied  by  careful  manipulation, 
the  obstruction  yielding  to  pressure.  This  treatment  is  aj)plicable  but 
rarely.  If  the  accumulation  is  sufficient  to  endanger  life,  the  aspirator 
may  be  used,  but  otherwise  interference  is  to  be  deprecated. 


CARCINOMA   OF   THE   KIDNEY. 

Causes. — iSTothing  is  definitely  known  of  the  causes  of  cancer  of  the 
kidney.  It  may  be  primary  or  secondary.  It  occurs  in  early  life 
— before  five — and  in  old  age,  youth  and  manhood  to  middle  age  being 
comparatively  exempt.  As  regards  sex,  cancer  of  the  kidneys  is  more 
common  in  men. 

Pathological  Anatomy. — Primary  cancer  rarely  involves  both  kid- 
neys, and  of  the  two  the  right  is  the  more  frequently  attacked.  When 
cancer  of  the  kidney  is  secondary,  the  organ  attacked  by  contiguity,  one 
only  is  affected,  but,  if  there  exists  a  general  carcinoma,  both  will  be  the 
seat  of  deposits.  The  cancerous  kidney  attains  to  great  size — accord- 
ing to  Rindfleisch  to  twelve  inches  in  length  and  six  inches  in  width, 
and  to  a  weight  of  sixteen  pounds  (Spencer  Wells).  This  enormous 
size  is  attained  in  a  very  short  time.  Again,  although  very  rarely,  the 
kidney  may  not  be  enlarged  by  cancer  deposits.  The  shape  of  the 
organ  may  be  exactly  preserved,  or  there  may  be  irregularities  and 
nodosities  ;  in  the  former  the  organ  on  section  presents  a  uniform 
whitish  or  yellowish  surface  ;  in  the  latter  the  cancer-masses  occur  in 
distinct  nodules,  separated  by  a  defined  line  from  the  normal  tissues, 
or  encapsulated.  The  vessels  of  renal  cancer  are  abundant,  large,  and 
have  thin  walls,  are  consequently  easily  ruptured,  the  blood  collecting 
in  large  excavations.  Usually  there  is  very  considerable  hypersemia 
of  the  interstitial  connective  tissue,  which  assumes  an  active  hyper- 
plasia. Sometimes  there  is  found  in  the  midst  of  a  mass  an  isolated 
soft  detritus,  made  up  of  cells  which  have  undergone  fatty  degenera- 
tion and  may  have  a  foul  odor.  The  cancer  elements,  according  to 
Waldeyer,*  whose  views  are  accepted  by  Ilindfleisch,f  develop  from 
the  epithelium  of  the  tubules.  The  form  taken  by  the  cancer  is  deter- 
mined by  the  relative  proportion  of  fibrous  stroma  and  cells  and  blood- 
vessels. The  more  abundant  the  vessels  and  cells,  the  softer  and  more 
rapidly  growing  the  cancer,  which  is  then  called  the  medullary  carci- 
noma.    If  the  fibrous  framework  or  stroma  is  in  excess,  then  the  can- 

*  Virchow's  "Archiv,"  op.  cit.  -j-  "Pathological  Anatomy,"  p.  512. 


CANCER   OF   THE   KIDNEY.  479 

cer  becomes  scirrlious.  The  cancer  may  spread  to  and  involve  the 
pelvis  and  ureter,  and  the  latter  may  be  filled  up  with  cancer-masses. 
The  pelvis  may  be  filled  with  blood-clots,  stratified  as  in  aneurism. 
The  cancer  elements  may  invade  the  renal  vein,  reach  into  the  vena 
cava  by  coagula,  whence  emboli  are  detached,  and  lodge  in  the  lungs. 
The  cancerous  kidney  may  contract  adhesions  to  adjacent  parts,  and\ 
is  apt  to  do  so,  or,  detached  by  its  increased  weight,  may  become  mi- 
gratory or  floating.  If  it  remains  in  its  own  position  and  enlarges  to 
the  enormous  extent  that  sometimes  occui's,  neighboring  organs  may 
be  much  displaced  and  compressed,  those  of  the  thorax  as  well  as  those 
of  the  abdomen. 

Symptoms. — Cancer  of  the  kidney  may  develop  to  a  considerable 
extent  without  producing  any  characteristic  symptoms.  Pain  may  be 
experienced  to  a  greater  or  less  degree  in  the  beginning,  but  it  does 
not  differ  from  pain  due  to  other  causes.  It  is  felt  in  the  lumbar 
region,  under  the  false  ribs,  external  to  the  spine,  and  is  a  sensation  of 
soreness  merely,  rather  than  the  acute,  lancinating  pain  traditional  of 
cancer.  With  or  without  pain,  haematuria  occurs,  and  is  the  first 
symptom  to  awaken  a  suspicion  of  the  nature  of  the  malady,  but  this 
symptom  is  present  in  one  half  of  the  cases  only.  It  is  not  constant, 
and  there  may  be  considerable  intervals  of  a  few  days,  weeks,  or 
months  between  the  haemorrhages.  Its  appearance  may  be  postponed 
until  near  the  end.  It  not  unfrequently  happens  that  some  external 
injury,  a  blow,  a  fall,  determines  the  haemorrhage  or  increases  its  vio- 
lence. Rarely  is  the  quantity  of  blood  sufficient  to  cause  dangerous 
exhaustion.  The  urine  may  present  a  faint,  smoky  hue  ;  it  may  be 
reddish  or  reddish-brown  ;  it  may  contain  clots  of  various  sizes.  The 
corpuscles  are  more  or  less  crenated  and  otherwise  altered  when  the 
urine  is  merely  smoky,  but  when  the  quantity  of  blood  is  considerable 
the  corpuscular  elements  are  normal.  So  long  as  the  blood  is  inti- 
mately mixed  with  the  urine,  there  is  no  pain  connected  with  it ;  but, 
when  clots  of  considerable  size  are  forced  through  the  ureter,  the  pain 
will  be  agonizing — only  less  severe  than  that  due  to  the  passage  of  a 
calculus.  Although  in  the  beginning  there  may  be  only  some  deep- 
seated  soreness,  or  no  pain  of  any  kind,  in  the  further  progress  of  the 
case  pains  will  come  on.  The  pain  may  be  deep  and  rather  dull  in 
the  neighborhood  of  the  kidney  or  in  the  lumbar  region,  or  it  may  be 
sharp,  lancinating,  and  radiate  along  the  intercostal  nerves,  or  down- 
ward into  the  hip,  the  whole  of  the  corresponding  lower  limb  feeling 
benumbed  and  heavy.  Sometimes  excruciating  sufferings  are  expe- 
rienced in  the  sciatic  nerve  by  pressure  of  cancerous  lymphatics,  and 
the  limb  rapidly  wastes.  Sufficient  enlargement  of  the  kidney  to  con- 
stitute a  tumor  is  the  most  constant  symptom.  In  sixty-four  cases  a 
tumor  of  the  abdomen  was  recognized  in  all  but  three,  and  in  nearly 
all  of  these  was  of  a  size  to  be  recognized  on  a  cursory  examination 


480  DISEASES   OF   THE   KIDNEY. 

(Roberts).  The  tumor  puslies  forward  into  the  anterior  part  of  the 
lumbar  region  and  grows  upward  into  the  hypochondrium  and  down- 
ward toward  the  iliac  regions.  In  children  the  tumor  attains  the  largest 
growth,  filling  the  entire  abdomen.  As  the  colon  lies  in  front  usually, 
and  as  the  material  of  the  cancerous  kidney  is  soft,  the  tumor  does  not 
furnish  a  dull  or  flat  note  on  percussion,  but  a  distinctly  tympanitic 
note.  Full  inspiration  or  expiration  does  not  affect  the  position  of  the 
tumor,  which  is  usually,  but  not  invariably,  immovable  ;  the  cancer- 
ous kidney  may  also  be  a  movable  or  a  floating  kidney.  By  carefully 
relaxing  the  abdominal  muscles  the  form  and  density  of  the  tumor 
may  be  ascertained.  It  will  be  found  somewhat  elastic,  round,  and 
smooth,  or  hard,  firm,  and  nodulai'.  There  may  be  a  ramification  of 
enlarged  veins  on  the  abdominal  surface  of  the  tumor,  and  it  may 
have  a  pulsation  in  it,  communicated  from  the  abdominal  aorta,  it  is 
probable.  If  haematuria  is  absent,  the  urine  may  be  normal  in  amount 
and  quality.  It  occasionally  happens  that  albumen  is  present  when 
there  is  no  blood,  because  of  a  coincident  Bright's  disease.  Uraemia 
does  not  occur  because  the  disease  is  unilateral,  but  both  organs  may 
be  involved.  When  a  calculus  is  present,  as  is  not  unusual,  jjyelitis  will 
complicate  the  renal  symptoms.  Particles  of  broken-down  tissue  and 
the  so-called  cancer-cells  are  sometimes  to  be  found  in  the  urine,  but 
unfortunately  there  is  no  distinctive  cancer-cell.  The  digestion  may 
be  unimpaired,  the  appetite  keen,  even  voracious,  but  the  rule  is  that 
the  appetite  is  poor,  there  is  nausea,  and  the  body  wastes.  With  the 
first  symptoms  there  is  emaciation,  which  ultimately  becomes  extreme. 

Course,  Duration,  and  Termination. — This  disease  does  not  pursue 
the  same  course  in  all  cases.  In  children  the  progress  is  more  rapid, 
the  mean  duration  being  seven  months  (Roberts),  whereas  in  adults 
the  average  duration  was  two  and  a  half  years.  In  some  cases  in  chil- 
dren the  duration  is  counted  by  weeks,  and  one  case  is  noted  as  occur- 
ring in  an  adult  which  lasted  eighteen  years.  The  termination  is  inva- 
riably in  death.  Sometimes  unexpected  improvement  takes  place,  but 
evil  symptoms  come  on  again  presently. 

Diagnosis. — Cancer  of  the  right  kidney  may  be  mistaken  for  a  tu- 
mor of  the  liver.  It  is  usually  possible  to  demonstrate  a  sulcus  be- 
tween the  liver  and  the  enlarged  kidney,  or  to  insinuate  the  fingers 
between  the  two.  The  position  of  the  colon  is  an  important  element, 
for  lying  in  front  of  the  kidney  modifies  the  percussion-note,  which  is 
dull-tympanitic  over  the  kidney  and  flat  over  the  liver.  From  an  en- 
larged spleen  it  is  to  be  distinguished  by  the  evolution  and  position 
of  the  tumor  ;  by  the  situation  of  the  colon — in  front  of  the  renal  and 
behind  the  splenic  tumor  ;  by  the  shape  and  thickness  of  the  tumor — 
the  spleen  having  a  rounded  margin  and  comparatively  thin  edge 
which  may  be  grasped  ;  by  the  history  of  the  case — malaria  or  leu- 
eocythemia  of  a  splenic  tumor  ;  by  the  urine,  containing  blood  and 


TUBERCULOSIS   OF   THE   KIDNEY.  481 

cancer  elements,  etc.  From  ovarian  tumor  the  differentiation  is  made 
by  the  position  of  the  growth,  the  mode  of  its  development,  by  its 
form  ;  by  the  position  of  the  colon,  again  ;  by  the  occurrence  of  hsema- 
turia,  etc.  From  accumulations  in  the  large  intestine,  in  the  csecum 
— the  descending  colon — the  kidney-tumor  is  recognized  by  its  size, 
outline,  position,  and  percussion,  by  hsematuria,  by  the  action  of  a 
cathartic,  or  irrigation  of  the  bowel.  As  cancerous  tumors  of  the  kid- 
ney sometimes  pulsate,  they  may  be  mistaken  for  aneurism.  If  the 
patient  be  placed  on  the  elbows  and  knees,  so  that  the  tumor  may 
glide  away  from  the  aorta  on  which  it  lies^  the  pulsation  will  cease. 
If  a  fixed  tumor,  this  expedient  can  not  be  practiced.  A  fixed  tumor 
of  that  kind  pulsating,  will  produce  no  expansile  movement.  It  will  be 
very  confusing  if  a  minute  communication  exist  between  the  aneurism 
and  pelvis  of  the  kidney,  for  then  hsematuria  will  coexist  with  a  tumor. 
Treatmeilt. — The  remedial  management  is  merely  symptomatic,,  and 
is  chiefly  confined  to  measures  for  the  relief  of  pain. 

TUBERCULOSIS   OF  THE   KIDNEY. 

Pathogeny. — The  deposit  of  tubercle  occurs  in  the  two  forms — 
disseminated,  localized.  In  the  disseminated  form,  gray  granulations 
are  scattered  through  the  renal  parenchyma,  and  are  developed  from 
the  sheaths  of  the  vessels,  and  this  form  is  a  part  of  a  general  morbid 
change.  It  is  the  localized  form  with  which  we  are  chiefly  concerned 
here.  The  deposit  of  tubercle-masses  begins  at  the  renal  papilla  by 
an  extension  of  the  morbid  process  taking  place  in  the  calyces  and 
pelvis.  The  miliary  nodules  aggregating,  undergo  the  cheesy  trans- 
formation, soften  in  the  center,  are  extruded,  carrying  with  them  the 
portion  of  tissue  embraced  in  the  deposit.  Thus  an  excavation  is 
established.  The  kidney  usually  increases  somewhat  in  size,  it  be- 
comes nodular,  and  the  capsule,  thickened  and  indurated,  contains 
various  foci  of  cheesy  deposit.  The  whole  organ  is  ultimately  con- 
verted into  a  mere  bag  with  thick  walls  and  projections  inwardly  of 
connective  -  tissue  septa,  the  remains  of  the  original  calyces.  The 
testes  and  epididymis  are,  in  the  majority  of  instances,  the  seat  of  the 
initial  changes,  and  spread  thence  to  the  kidneys,  or  they  may  begin 
in  the  bladder  and  extend  thence  into  the  kidneys.  The  same  cheesy 
infiltration  takes  place  in  the  pelvis,  ureters,  and  bladder. 

Symptoms. — The  urine  is  increased  in  amount,  and  contains,  when 
the  disease  is  developed  fully,  blood  and  pus,  the  reaction  is  acid,  and 
albumen  is  present.  In  the  further  progress  of  the  case,  the  urine 
becomes  ammoniacal,  alkaline,  and  thick  with  pus  and  detritus.  When 
the  disease  has  reached  the  sub-mucous  tissue,  shreds  of  elastic  tissue, 
and  fragments  of  cheesy  matter,  which  indicate  clearly  the  nature  of 
the  destructive  changes,  appear  in  the  urine.  Micturition  is  frequent 
31 


482  DISEASES   OF   THE   KIDNEY. 

and  more  or  less  painful.  This  is  due  to  the  tubercular  ulceration  of 
the  mucous  membrane  of  the  bladder,  and  the  catarrh  which  accom- 
panies it.  More  or  less  pain  is  experienced  in  the  lumbar  region, 
which  may  be  a  feeling  of  soreness  and  fatigue  combined,  or  of  acute 
pain,  paroxysmal  in  character.  Besides  the  lumbar  pain,  there  are 
paroxysmal  attacks  of  pain  in  the  back,  extending  along  the  ureter, 
attended  with  frequent  and  painful  micturition,  produced  by  the  pas- 
sage of  shreds  of  tissue  or  cheesy  masses.  There  may  be  no  pain. 
Obstruction  to  the  ureter  taking  place,  there  may  ensue  an  enlarge- 
ment of  the  kidney  of  sufficient  size  to  constitute  a  tumor.  The  ob- 
struction yielding,  the  accumulated  pus  and  urine  will  flow  away,  and 
the  tumor  will  collapse  ;  but,  when  the  tumor  once  forms,  although  it 
may  vary  in  size,  it  does  not  entirely  disappear.  With  the  progress 
of  the  tubercular  ulceration,  there  is  increasing  destruction  of  the 
renal  substance,  and  hence  the  quantity  of  urine  is  constantly  declining. 
As  both  kidneys  are  usually  affected,  urgemic  symptoms  come  on,  when 
the  excretion  of  urea  and  other  effete  materials  is  prevented.  Usually, 
however,  the  patient  is  carried  off  by  the  progress  of  the  tubercular 
ulceration  in  the  intestinal  canal  and  lungs.  In  the  author's  cases, 
there  were  simultaneous  pulmonary  lesions,  which,  however,  seemed  to 
make  but  little  progress.  Death  occurs  by  exhaustion,  or  with  some 
head  troubles. 

Course,  Duration,  and  Termination. — The  course  and  duration  are 
much  affected  by  the  existence  of  general  tuberculosis,  by  the  extent 
of  mischief  in  both  kidneys,  and  by  the  degree  in  which  the  bladder 
is  implicated.  The  duration  rarely  exceeds  one  year,  though  there  are 
occasional  examples  lasting  two,  even  three  years.  If  the  bladder  is 
much  affected,  the  pain  and  irritation  and  the  loss  of  sleep  from  fre- 
quent micturition  rapidly  exhaust  the  vital  powers.  If  both  kidneys 
are  largely  damaged,  the  case  will  be  terminated  by  cerebral  haemor- 
rhage, or  by  coma  and  convulsions. 

Treatment.- — The  best  results  as  regards  prolongation  of  life  are 
obtained  by  the  use  of  quinia  in  considerable  doses  (five  grains  ter 
in  die)  and  eucalyptol.  To  relieve  the  irritable  bladder  and  permit 
sleep,  the  most  suitable  remedies  are  chloral  and  morphia  by  supposi- 
tory or  enema.  If  the  cystitis  is  very  severe,  and  the  urine  ammoni- 
acal,  good  results  are  obtained  by  the  author  by  irrigation  of  the 
bladder  with  a  weak  solution  of  salicylic  acid  and  borax. 


ECHINOOOCOUS   OF   THE   KIDNEY— HYDATID   CYST   OF    THE 

KIDNEY. 

Definition. — Echinococcus  of  the  kidney,  like  echinococcus  of  the 
liver,  is  the  immature  or  larval  condition  of  the  tcenia  echinococcus, 
the  tape-worm  of  the  dog. 


HYDATIDS   OF   THE   KIDNEY.  483 

Pathogeny. — According  to  Davaine,  this  parasite  is  rarely  found  in 
the  kidney.  It  is  a  sac  composed  of  several  layers,  transparent  and 
hyaline,  the  mother-sac,  and  within  it  are  contained  a  watery  fluid  and 
a  number  of  small  vesicles  (daughter-vesicles),  attached  to  the  brood- 
capsule  (mothei'-sac)  or  floating  freely.  These  daughter-vesicles  vary 
in  size  from  a  grape-seed  to  an  orange — the  largest  containing  their 
own  progeny,  or  granddaughter  -  vesicles.  As  the  daughter-vesicles 
enlarge,  the  brood-capsule  with  its  germinating  layer  also  enlarges. 
Within  each  capsule  or  vesicle  is  seen  the  scolex,  or  so-called  head  with 
its  suckers  and  row  of  booklets.  The  fluid  of  the  vesicles  is  watery, 
albuminous,  and  saline,  and  contains,  besides  chloride  of  sodium,  crys- 
tals of  uric  acid,  oxalate  of  lime,  triple  phosphates,  and  plates  of  cho- 
lesterine.  The  parent-vesicle  is  inclosed  in  a  vascular,  white,  dense 
connective-tissue  tunic  or  envelope,  one  half  to  two  or  three  lines  in 
thickness,  and  firmly  adherent  to  the  surrounding  gland-substance. 
The  size  of  the  cysts  varies  from  a  small  marble  to  a  child's  head,  and 
it  is  situated  in  the  substance  of  the  kidney,  and  occasionally  between 
the  capsule  and  the  gland-structure.  The  pressure  of  the  enlarging 
cyst  induces  atrophy  of  the  adjacent  renal  substance,  until  ultimately 
the  whole  organ  may  be  destroyed.  Rupture  may  take  place  into  the 
pelvis  of  the  kidney,  but  not  into  the  peritoneum,  this  untoward  result 
being  prevented  by  a  limiting  adhesive  peritonitis.  Adhesions  are  also 
formed  with  neighboring  organs.  Sometimes  the  cysts  are  sterile,  and 
consist  of  a  single  cavity.  The  growth  may  be  arrested  and  the  cyst 
undergo  calcareous  degeneration  mixed  with  a  fatty  change.  In  two 
thirds  of  the  cases  a  rupture  of  the  cyst  takes  place  into  the  pelvis,  and 
pyelitis  is  produced  thei'eby. 

Symptoms. — As  the  parasite  is  deposited  in  one  kidney — a  rule  to 
which  there  are  but  few  exceptions — and  as  no  disturbance  is  caused 
in  the  functions  of  the  affected  organ  until  the  parasite  has  attained  a 
certain  development,  it  is  obvious  that  the  first  period  of  growth  will 
escape  recognition.  As  the  tumor  enlarges,  neighboring  organs  are 
displaced,  and  as  inflammatory  attacks  ai'e  excited  and  adhesions 
formed,  these  will  be  accompanied  by  attacks  of  pain  and  f  everishness. 
Usually  only  the  symptom  of  a  tumor,  smooth  and  elastic,  in  the  flank, 
is  experienced,  and  for  which  advice  is  sought.  Accoi'ding  to  Roberts's 
statistics,  of  sixty-three  cases  of  hydatids  of  the  kidney,  only  eighteen 
presented  the  symptom  of  a  tumor,  varying  in  size  from  an  orange  to 
an  adult's  head.*  Fluctuation  was  distinct  in  part,  feeble  in  others, 
and  not  perceived  in  the  rest.  The  most  characteristic  symptom  is 
the  "  purring  tremor,"  "  the  hydatid  thrill,"  unfortunately  a  symptom 
which  is  not  often  encountered.  It  can  be  produced  only  when  therfe 
are  numerous  daughter-vesicles  inclosed  in  the  mother-sac,  the  thrill 

*  "  Urinary  and  Renal  Diseases,"  p.  o12. 


484  DISEASES   OF   THE   KIDNEY. 

being  caused  by  the  collision  of  these  elastic  bodies.  The  tumor  will 
usually  have  the  colon  in  front,  but  it  may  be  at  one  side.  The  dull- 
ness on  percussion  will  be  much  influenced  by  the  position  of  the  bowel, 
which  must  always  be  taken  into  consideration.  As  the  cyst  in  a  ma- 
jority of  cases  tends  to  rupture  into  the  pelvis  of  the  kidney,  the  symp- 
toms connected  with  this  are  of  great  importance.  Vesicles,  shreds  of 
the  germinating  layer,  and  an  emulsion  of  milky  appearance  contain- 
ing fragments,  booklets,  and  oil-drops,  are  discharged  with  the  urine, 
and  at  once  indicate  the  character  of  the  case,  the  microscope  being 
used  to  find  the  hooklets.  The  rupture  of  a  sac  into  the  pelvis  of  the 
kidney  is  usually  announced  by  the  occurrence  of  sharp  pains  in  the 
region  of  the  kidney,  with  a  sensation  of  something  giving  way.  This 
seems  all  the  more  probable  if,  as  has  been  the  case,  the  patient  has  re- 
ceived a  blow  in  the  side,  followed  by  the  sensation  of  something  giving 
way.  The  pain  descends  by  the  ureter,  the  testicle  is  retracted,  the  sur- 
face cold,  and  the  pulse  feeble.  The  severe  attacks  of  renal  colic  are 
comparatively  rare,  but  some  pain  in  the  loin  and  down  the  ureter  is 
usual.  The  paroxysms  do  not  continue  longer  than  a  few  hours,  or  a 
day  or  two,  to  be  resumed  again  at  variable  intervals  of  a  few  weeks,  sev- 
eral months,  or  even  three  years.  When  the  vesicles  reach  the  bladder, 
the  pain  of  renal  colic  ceases  ;  but  new  troubles  arise  in  the  attempt  to 
pass  these  bodies  by  the  urethra.  Violent  vesical  tenesmus  comes  on, 
pain  is  felt  at  the  glans  penis,  and  with  severe  straining  the  vesicles 
are  passed,  but  not  unfrequently  the  aid  of  the  catheter  is  necessary 
to  empty  the  bladder.  If  there  be  a  single  mother-vesicle,  the  dis- 
charge of  the  daughter-progeny  may  end  the  symptoms  by  the  shrink- 
ing and  closure  of  the  sac.  The  sac  may  be  much  reduced  in  size  by 
the  discharge,  but  fills  up  again,  the  same  phenomena  being  repeated 
from  time  to  time. 

Course,  Duration,  and  Termination, — The  course  of  hydatids  of  the 
kidney  is  chronic,  and  the  duration  uncertain.  If  a  single  cyst  is  pres- 
ent, the  discharge  of  its  contents  may  terminate  the  case,  but  usually 
there  are  several  discharges.  The  cases  may  terminate  by  rupture  into 
the  peritoneum,  which  is  unusual,  by  bursting  into  a  bronchus,  by  ex- 
citing pleuritis,  by  suppuration  in  the  sac,  by  some  intercurrent  malady, 
and  by  recovery,  which  occurs  in  about  two  thirds. 

Diagnosis. — If  there  be  present  a  tumor,  and  parasites  are  discharged 
with  the  urine,  the  size  of  the  tumor  diminishing,  there  can  be  no 
doubt.  Mici'oscopic  examination  will  determine  the  character  of  the 
milky  fluid,  or  shreds  passed.  If  no  tumor  can  be  detected,  the  dis- 
charge of  vesicles  with  the  symptoms  of  nephritic  colic  will  indicate 
the  probable  seat  of  the  mother-sac.  If  a  tumor  exist  without  the  dis- 
charge, it  can  not  be  distinguished  from  hydronephrosis. 

Treatment. — The  pain  and  disturbance  caused  by  the  passage  of 
the  cysts  must  be  treated  as  renal  colic.     If  the  cysts  are  enlarging, 


MOVABLE   KINDEY.  485 

an  attempt  should  be  made  to  destroy  them.  Electrolysis  has  been 
proposed  for  this  purpose,  but  it  appears  the  attempts  which  have  been 
made  have  not  succeeded.  Injection  with  tincture  of  iodine,  or  with 
bile,  which  seems  very  poisonous  to  these  parasites,  should  be  prac- 
ticed. 

MOVABLE   KIDNEY. 

Definition. — By  this  term  is  meant  a  kidney  become  abnormally 
movable.     It  is  sometimes  called  Jloating  kidney. 

Causes. — The  kidney  may  have  an  unusual  mobility,  by  reason  of 
anatomical  peculiarities.  The  peritoneum  may  be  reflected  in  front 
and  behind,  constituting  a  mesos  permitting  free  motion  to  the  oi-gan. 
In  its  natural  position  imbedded  in  fat  and  having  the  peritoneum  in 
front,  and  unsupported  by  ligaments,  it  is  so  placed  as  to  be  readily 
dislocated.  Should  the  fat  be  absorbed,  or  the  peritoneum  relaxed,  the 
kidney  becomes  abnormally  movable.  This  disability  is  more  common 
in  women  than  in  men  (ten  to  two,  about),  a  difllerence  due  to  two 
factors — to  tight  lacing,  and  to  pregnancy.  Pregnancy  by  the  great 
distention  of  the  abdomen,  relaxes  the  peritoneum,  and  thus  removes 
the  principal  support.  Tight  lacing  forces  the  liver  down,  which 
pushes  the  kidney  before  it,  but  on  the  left  side  the  organs  have  more 
room.  The  right  kidney  is  afiEected  in  the  majority — in  Roberts's  col- 
lection of  sixty-five  cases,  the  right  kidney  was  movable  in  forty-two, 
the  left  in  nine,  and  both  in  fourteen.  If  the  weight  of  the  organ  is 
increased  by  any  cause,  the  tendency  to  displacement  is  proportionately 
increased.  Usually,  however,  an  enlarging  kidney  contracts  inflam- 
matory adhesions  to  neighboring  parts,  and  thus  dislocation  is  pre- 
vented. 

Pathological  Anatomy. — The  congenital  movable  kidney  is  distin- 
guished from  the  acquired  by  abnormal  arrangement  of  the  vessels  or 
peritoneum,  or  of  both.  In  the  acquired  mobility  the  organ  is  rather 
elongated,  without  fat,  and  detached  from  the  peritoneum.  The  degree 
of  mobility  varies,  but  the  extreme  length  is  not  greater  than  the 
length  of  the  vessels  which  form  the  pedicle.  Attacks  of  perinephritis 
are  common,  and  hence  the  kidney  may  be  surrounded  by  old  exuda- 
tions and  bands  of  adhesion.  The  dislocated  kidney  may  become  at- 
tached again  and  cease  to  give  any  more  trouble. 

Symptoms. — When  displaced,  the  kidney  may  descend  to  the  mar- 
gin of  the  iliac  region,  but  it  is  usually  felt  about  midway  between  the 
inferior  border  of  the  ribs  and  the  umbilicus.  If  the  patient  is  thin, 
the  outline  of  the  organ  can  be  distinctly  made  out,  and  it  may  even 
be  grasped  by  the  thumb  and  fingers,  the  pressure  producing  a  sicken- 
ing pain  and  faintness.  The  kidney  may  also  be  pushed  about,  and 
upward  and  backward  into  its  proper  position,  but  it  will  not  remain, 
descending  as  soon  as  the  support  is  withdrawn.     Respiration  changes 


486  DISEASES   OF   THE   KIDNEY. 

its  position  also  :  it  descends  on  full  inspiration  ;  ascends  on  full  ex- 
piration. Percussion  does  not  afford  a  flat  note,  but  a  dull  tympanitic 
note.  Over  the  normal  site  occupied  by  the  kidney,  there  will  be, 
instead  of  a  flat  note  on  percussion,  a  hollow  tympanitic  sound. 

Besides  the  presence  of  a  movable  body  in  the  abdomen,  which 
always  excites  apprehension,  there  may  be  no  other  symptom.  In  other 
cases  there  may  be  only  soreness  in  the  kidney,  and  a  deep-seated  sense 
of  aching  and  pain,  with  a  dragging  feeling  in  the  back  and  loins. 
Usually,  the  most  pronounced  symptoms  are  those  connected  with  the 
digestive  organs  :  ■  the  appetite  is  poor,  the  bowels  are  constipated, 
there  is  much  flatulence,  and  at  the  same  time  they  suffer  from  pain  in 
the  rambling  kidney,  and  aching  and  dragging  in  the  loins.  This 
group  of  symptoms  has  a  paroxysmal  character — there  are  intervals 
not  of  entire  exemption,  but  of  relief.  The  intestinal  disorders  some- 
times take  the  character  of  cholera  morbus,  the  attacks  occurring  every 
few  days  or  weeks,  and  between  them  the  digestion  is  troubled,  and 
there  is  much  flatulent  distention.  Now  and  then  there  are  cerebral 
attacks — extreme  vertigo,  headache,  nausea,  and  vomiting,  due  prob- 
ably to  twisting  of  the  ureter  and  retention  of  urine,  congestion  of  the 
kidney,  etc.,  and  followed  by  bloody  urine,  purulent  sediment,  and 
finally  a  copious  urinary  discharge,  the  symptoms  subsiding.  Again, 
in  other  cases,  there  will  be  much  pain  and  tenderness  experienced 
about  the  kidney,  and  requiring  confinement  to  bed,  feverishness,  a 
coated  tongue,  headache,  scanty,  acid  urine,  etc. — symptoms  probably 
due  to  attacks  of  local  peritonitis  or  adhesive  inflammation.  In  a  case 
of  displaced  right  kidney  in  a  male,  there  were  obstinate  constipation, 
small,  flattened  faeces,  persistent  flatus  with  the  sensation  of  passing  an 
obstacle,  due  to  the  position  of  the  kidney  against  the  ascending  colon. 
In  all  cases,  causing  symptoms,  there  is  much  hypochondriasis,  or  de- 
pression of  spirits,  even  suicidal  feelings. 

Course,  Duration,  and  Termination. — The  cases  continue  indefinitely. 
It  sometimes  happens  that  the  kidney  secures  firm  attachments  again, 
but  the  author  has  seen  but  a  single  example  of  such  termination,  A 
dislocated  kidney  is  more  liable  to  degenerative  changes  than  a  fixed 
one. 

Diagnosis. — As  no  other  tumor  behaves  as  the  movable  kidney,  the 
diagnosis  ought  to  be  easy.  The  diagnosis  rests  on  these  data  :  the 
tumor  has  the  shape  and  size  of  the  kidney  ;  it  descends  from  the  posi- 
tion occupied  by  the  kidney,  and  can  be  pushed  back  into  the  same  ; 
it  has  a  special  sensibility  ;  the  position  which  the  kidney  normally 
occupies  is  found  to  be  vacant. 

Treatment. — As  the  chief  distress  arises  from  the  movable  condition 
of  the  kidney,  an  attempt  should  be  made  to  confine  it  to  its  proper 
place  by  a  suitable  bandage.  The  patient  must  be  recumbent,  the 
muscles  of  the  abdomen  relaxed  ;  then  the  kidney  is  pushed  back,  a 


PERINEPHRITIS.  487 

compress  is  so  placed  as  to  prevent  its  descending,  and  a  closely  fitting 
bandage  must  then  be  fastened  around  the  abdomen,  so  arranged  that 
the  support  is  from  below  upward.  Attention  must  be  paid  to  the 
diet,  and  flatulent-forming  food  given  up  entirely.  Constipation  must 
be  avoided,  and  the  bowels  kept  in  a  soluble  state.  If  anaemia  exist,  a 
course  of  chalybeate  tonics  will  be  necessary.  The  secretion  of  urine 
should  be  closely  observed,  to  discover  changes  in  time. 


PERINEPHRITIS. 

Definition. — Bj  perinephritis  is  meant  an  inflammation  of  the  loose 
connective  tissue  about  the  kidney.  This  term  is  comparable  to  perity- 
phlitis. As  the  ordinary  result  is  suppuration,  it  may  be  comprehended 
in  the  term  perinephric  abscess,  as  employed  by  Trousseau. 

Causes. — Penetrating  wounds,  contusions,  and  even  strain  (Trous- 
seau) will  excite  inflammation  of  the  perinephritic  connective  tissue. 
Pelvic  cellulitis  may  extend  upward  by  the  subperitoneal  connective 
tissue,  and  ultimately  involve  the  renal.  This,  although  often  a  puer- 
peral process,  may  arise  from  operations  on  the  pelvic  organs,  etc. 
Operations  on  the  rectum  and  inflammatory  affections  about  the  blad- 
der may  also  produce  the  same  result.  Chronic  pyelitis  may  extend 
to  and  involve  the  perinephric  connective  tissue.  This  disease  occurs 
at  adult  life  till  old  age,  and  is  more  common  in  men  than  in  women. 

Pathological  Anatomy. — The  connective  tissue  is  at  first  the  seat  of 
an  intense  hypersemia  ;  suppuration  soon  follows,  the  purulent  elements 
being  mixed  with  blood,  and  presenting  therefore  a  grumous  aspect ; 
the  area  of  suppuration  is  not  limited,  the  boundaries  of  the  pus  being 
shreds  of  breaking-down  tissue,  the  abscess  enlarging  irregularly.  The 
pus  presently  becomes  yellowish  and  homogeneous,  and  something  like 
well-defined  limits  surround  it,  but  the  tendency  is  to  spread  along  the 
retroperitoneal  connective  tissue.  An  enormous  accumulation  may 
take  place.  The  disposition  of  the  abscess  occurs  in  various  ways  :  it 
may  rupture  into  the  peritoneum,  exciting  general  peritonitis  ;  it  may 
dissect  through  and  discharge  externally  in  the  lumbar  region  ;  it  may 
open  the  colon  and  discharge  by  the  bowel ;  it  may  burrow  along  the 
psoas  muscle  and  open  underneath  Poupart's  ligament,  or  at  the  lesser 
trochanter,  etc. 

Symptoms. — Pain  is  a  very  usual  and  persistent  symptom.  Often 
it  begins  with  the  blow  or  strain,  and  is  a  deep-seated  aching  in  the 
lumbar  region,  increased  by  firm  pressure,  by  bending  the  body,  and 
is  not  relieved  by  changes  of  position,  but  it  sometimes  ceases  for 
days,  even  weeks,  but  when  it  returns  is  more  severe  than  before. 
With  the  first  pain  there  is  more  or  less  chilliness,  followed  by  fever, 
general  malaise,  nausea,  anorexia,  a  coated  tongue,  etc.,  the  fever 
rising  to  103°,  104°,  or  even  higher.     The  fever  has  the  remittent 


488  DISEASES   OF   THE   KIDNEY. 

type,  with  a  morning  remission,  and  there  is  considerable  sweating, 
especially  toward  morning.  A  severe  rigor  announces  suppuration,  and 
chills  occur  subsequently  irregularly,  and  are  followed  by  high  fever 
and  profuse  sweats.  The  body  emaciates  ;  the  appetite  is  gone  ;  there 
is  vomiting  ;  an  obstinate  constipation,  requiring  active  purgatives  to 
relieve  it,  comes  on  ;  the  skin  acquires  the  yellowish,  earthy  hue  or 
fawn-color  of  suppuration.  After  a  time,  a  swelling  is  discovered  in 
the  flank,  and  the  depression,  which  normally  exists  in  the  lumbar 
region,  assumes  a  convex  shape.  On  careful  manipulation,  deep- 
seated  fluctuation  may  be  detected.  If  left  to  pursue  the  course  un- 
disturbed, the  pus  finally  points  in  the  lumbar  region.  The  pus  may 
be  odorless,  or  it  may  have  a  fecal  odor  without  any  communication 
with  the  bowel.  If  the  abscess  discharges,  and  there  is  no  complica- 
tion, the  condition  of  the  patient  at  once  improves,  the  fever  ceases, 
the  appetite  returns.  If  the  pus  burrows  downward,  the  duration  is 
more  protracted,  and  there  is  much  pain,  the  abscesses  opening  in  the 
groin.  Discharge  taking  place  by  the  lumbar  region,  extensive  em- 
physema, occupying  the  whole  extent  of  the  back,  may  occur  (Trous- 
seau). In  such  cases  communication  is  established  with  the  bowel, 
and  hence  the  emphysema  is  due  to  the  intestinal  gases.  Faeces  may 
be  discharged  by  the  lumbar  opening,  and  recovery  ensue.  If  rupture 
into  the  peritoneal  cavity  occurs,  intense  peritonitis,  with  the  usual 
symptoms,  will  be  excited.  Rupture  into  the  pelvis  of  the  kidney 
will  be  announced  by  the  sudden  discharge  of  pus  in  the  urine. 

Course,  Duration,  and  Termination.  —  The  symptoms  are  very 
obscure  until  the  fluctuating  tumor  appears  ;  the  cases  then  pursue 
a  very  uniform  course,  and  the  primary  form,  rapid  course.  Discharge 
of  pus  may  terminate  an  uncomplicated  case  in  three  or  four  weeks. 
Recovery  is  the  usual  termination  in  such  cases.  Extensive  and  pro- 
tracted suppuration  will  induce  a  typhoid  state  and  death  by  exhaus- 
tion. Rupture  into  the  intestinal  canal  is  rapidly  fatal.  When  com- 
munication is  established  with  the  colon,  recovery  may  ensue,  but  the 
result  is  doubtful.  When  the  abscess  is  secondary  to  puerperal  pro- 
cesses, the  termination  is  usually  in  death.  In  a  few  cases,  the  in- 
flammation of  the  perinephric  tissue  undergoes  resolution  without 
suppuration.  The  morbid  process  may  produce  or  succeed  to  pyelitis, 
or  the  kidney  itself  may  become  diseased — results  which  aggravate 
the  existing  disease. 

Diagnosis. — Perinephritis  may  be  confounded  with  hydronephrosis^ 
echinococcus,  and  cancer.  In  all  of  these  diseases  a  tumor  exists  :  in 
perinephritis,  accompanied  by  fever  and  sweats  and  the  other  evi- 
dences of  suppuration  ;  in  hydronephrosis  and  echinococcus,  an  en- 
larging tumor  without  pain  ;  in  cancer,  a  painful  tumor  and  hgema- 
turia.  Perinephritic  abscess  tends  outwardly  to  point  in  the  lumbar 
region,  or  downward,  in  the  groin,  while  the  other  tumors  grow  for- 


CEREBRAL   HYPER JilMIA.  489 

ward  and  downward  into  the  peritoneal  cavity.     Pyelitis  with  tumor 
is  distinguished  from  perinephritis  by  the  condition  of  the  urine. 

Treatment. — With  the  first  symptoms,  leeches  may  be  applied  to 
the  lumbar  region,  followed  by  ice.  Purgatives  should  be  adminis- 
tered. If  there  is  much  pain,  morphia  is  necessary.  Large  doses  of 
quinia  (ten  grains  every  four  hours)  should  be  given  with  the  view 
to  check  the  migration  of  the  white  corpuscles,  and  preferably  with 
morphia,  although  the  pain  may  not  be  gi-eat.  As  soon  as  suppuration 
occurs,  supporting  measures  are  required.  Malt  liquors,  a  generous 
diet,  alcoholic  liquors,  and  quinia  are  the  most  appropriate  means.  A 
free  incision  should  be  practiced  as  early  as  possible,  and  di-ainage 
established. 


DISEASES    OF    THE    NERVOUS    SYSTEM. 


OEREBRAIi  HYPEILEMIA. 

Definition. —  Cerebral  hypermmia,  or  cerebral  congestion,  is  a  mal- 
ady characterized  by  an  increase  in  the  amount  of  blood  in  the  brain. 
The  hypersemia  may  be  arterial,  or  active ;  venous,  or  passive. 

Causes. — Any  condition  diminishing  the  amount  of  arterial  blood 
in  other  parts  will  divert  a  larger  quantity  to  the  cranial  cavity :  com- 
pression of  the  abdominal  aorta,  ligation  of  an  important  artery,  are 
examples.  The  suppression  of  an  habitual  discharge  of  blood — as  that 
of  haemorrhoids,  for  illustration — is  alleged  to  produce  the  same  effect. 
Cerebral  congestion  occurs  in  the  cold  stage  of  an  ague,  and  is  also 
produced  by  the  application  of  cold  to  the  surface  of  the  body.  Pro- 
longed intellectual  effort,  insolation,  or  sunstroke,  protracted  wakeful- 
ness, over-indulgence  in  alcoholic  beverages,  and  the  use  of  such  nar- 
cotics as  belladonna,  are  supposed  to  induce  congestion  of  the  brain. 
Hypertrophy  of  the  heart,  fullness  of  the  general  vascular  system, 
and  general  plethora,  are  also  alleged  to  have  this  effect,  but  grave 
doubts  may  well  exist  on  this  point.  Passive  congestion  is  produced 
when  there  is  an  obstacle  to  the  return  of  blood  from  the  cranial 
cavity,  as  when  the  superior  vena  cava  and  the  jugular  are  com- 
pressed by  intra-thoracic  or  cervical  tumors,  or  when  the  venous  system 
is  overfilled  by  mitral  or  tricuspid  disease.  Venous  stasis  is  also  caused 
by  atheromatous  degeneration  of  the  arterial  tunics,  feebleness  of  the 
cardiac  contractions,  and  lowered  vascular  tonus. 

Pathological  Anatomy. — There  are  no  structural  changes  beyond 


490  DISEASES   OF   THE   NERVOUS   SYSTEM. 

an  increase  in  the  amount  of  blood,  the  displacement  of  a  correspond- 
ing amount  of  cerebro-spinal  fluid,  and  mechanical  compression  of  the 
cerebral  matter.  The  veins  of  the  dura  mater  are  distended,  but  still 
more  those  of  the  pia  mater  and  choroid  plexus.  The  sinuses  are 
also  overfilled.  The  convolutions  are  somewhat  flattened,  and  the 
perivascular  lymph-spaces  are  closed  by  the  approximation  of  their 
walls.  On  section,  more  blood  than  normal  flows  out  of  the  divided 
vessels,  and  the  puncta  vasculosa  are  more  numerous.  If  the  hyper- 
semia  is  of  long  standing,  or  if  repeated  attacks  have  occurred,  the 
changes  are  more  pronounced.  The  veins  enlarge  and  become  vari- 
cose, and  small  arteries  previously  invisible  come  into  permanent  view, 
and  aneurismal  dilatations  form  on  the  arterioles.  There  may  be  mi- 
nute extravasations  and  capillary  hemorrhages,  the  evidence  of  which 
is  afforded  in  old  cases  by  pigment  deposits  and  blood-crystals  in  the 
lymph-spaces.  Transudations  of  serum  may  occur  in  the  subarach- 
noid spaces  and  in  the  ventricles,  and  also  in  the  perivascular  sheaths, 
whence  it  follows,  in  old  cases,  that  permanent  dilatation  of  these 
spaces  may  have  occurred,  producing  the  etat  crible. 

Symptoms. — There  are  three  well-marked  forms  of  cerebral  hyper- 
semia — the  light,  the  severe,  and  the  apoplectic  (Jaccoud).  In  the  light 
form  the  onset  is  gradual,  and  among  the  first  symptoms  is  headache, 
which  is  soon  followed  by  characteristic  signs  :  the  headache  is  dull 
and  heavy,  with  occasional  sharp,  lancinating  pains,  increased  by  mo- 
tion or  sudden  shocks,  or  by  light  and  sound  ;  there  is  inaptitude 
for  any  mental  effort,  and  the  attempt  to  exercise  the  mind  causes  a 
sense  of  cerebral  exhaustion  ;  there  is  singing  in  the  ears,  with  other 
subjective  noises  ;  the  conjunctivae  are  injected,  the  retina  is  sensitive 
to  light,  and  there  are  flashes  of  light  and  moving  objects  before  the 
eyes  ;  the  sleep  is  fitful  and  unrefreshing,  and  disturbed  by  dreams  of 
a  terrifying  kind  ;  vertigo  occurs,  and  the  muscular  movements  are 
uncertain  and  fatiguing  ;  the  sensations  are  disordered,  and  numbness 
and  tingling  are  felt  in  the  extremities  ;  the  stomach  is  uncertain,  and 
nausea  is  often  experienced  ;  and  the  heart  is  exceedingly  irritable, 
the  pulse  rising  considerably  with  the  least  mental  or  physical  effort 
or  emotional  excitement.*  The  severe  form  may  develop  out  of  the 
light,  or  it  may  come  on  without  any  prodromic  symptoms.  As  com- 
pared with  the  light  form,  we  find  the  headache  is  more  intense  ;  the 
special  senses  are  more  irritable  and  intolerant  of  light  and  sound  ; 
the  mind  more  disturbed,  ideation  more  confused,  illusions  and  hallu- 
cinations occurring  ;  the  wakefulness  more  obstinate  and  complete  ; 
the  motor  functions  more  excited,  the  movements  more  irregular  and 
uncertain,  jactitations  appearing  ;  the  sensory  functions  are  more  per- 
verted ;  besides  the  headache,  are  neuralgic  pains,  especially  in  the 

*  Hammond,  "  Cerebral  HypersBmia,"  p.  48. 


CEREBRAL   HYPERyEMIA.  4.9I 

fifth,  numbness  and  tingling  being  felt  in  the  extremities  ;  the  vertigo 
is  more  decided,  the  upright  position  being  maintained  with  difficulty, 
and  all  coordinated  and  combined  acts  being  executed  with  difficulty  ; 
the  action  of  the  heart  is  more  excited,  the  pulsations  irregular  and 
rapid,  and  the  least  effort  sending  the  beat  up  many  times  ;  the  head 
is  moi'e  decidedly  warm,  the  eyes  more  suffused,  more  deeply  injected, 
the  eyelids  more  swollen  ;  the  stomach  is  more  disordered,  and  nausea 
and  vomiting  are  excited  by  effort  of  the  mind,  or  by  attempt  at  close 
attention.  The  symptoms  indicate  the  approach  of  acute  maniacal 
excitement,  or  acute  inflammation  ;  but  the  mind,  although  occupied 
by  illusions  and  hallucinations,  is  still  able  to  correct  them  or  reason 
correctly  about  them,  and  the  febrile  condition  does  not  yet  exist. 
The  symptoms  may  subside  in  a  day  or  two,  and  health  be  restored 
in  a  few  days,  or,  the  case  unrelieved  may  then  pass  into  the  stage  of 
depression  ;  torpor  succeeding  to  exalted  activity,  drowsiness  to  wake- 
fulness, coma  to  delirium.  In  adults,  convulsions  rarely  occur  in  the 
course  of  the  severe  form,  but  are  usual  in  children. 

In  the  apoplectiform  variety  of  cerebral  congestion,  the  patient  may 
suddenly  pass  into  unconsciousness,  with  the  usual  phenomena  attend- 
ing the  apoplectic  attack  ;  there  is  complete  muscular  relaxation,  in- 
voluntary evacuations  may  occur,  but  the  reflex  movements  are  not  in 
abeyance,  and  in  some  minutes  or  hours  the  patient  returns  to  con- 
sciousness, somewhat  confused,  however,  and  does  not  entirely  recover 
for  some  days.  Without  losing  consciousness,  he  may  suffer  con- 
fusion of  mind,  extreme  vertigo,  have  defects  of  speech,  or  an  entiro 
loss  of  memory  for  words,  numbness,  tingling,  and  paresis  of  the  mem- 
bers, nausea  and  vomiting,  etc.,  also  coming  on  suddenly,  and  dis- 
appearing after  some  hours  and  days  without  permanent  disability. 
The  symptoms  belonging  to  the  venous  or  passive  form  of  hyperaemia 
are  much  less  pronounced,  although  in  some  respects  similar.  There 
is  headache,  but  a  sensation  of  heaviness  and  dullness  rather  than 
acute  pain  ;  the  eyelids  are  swollen  and  puffy,  but  the  conjunctivae  are 
not  injected  ;  the  superficial  veins  are  full,  but  the  scalp  is  cool ;  smg- 
ing  in  the  ears  and  impaired  hearing  are  noted  ;  vision  is  dull,  and 
floating  objects  are  seen  before  the  eyes  ;  the  mental  operations  are 
dull  and  confused  ;  somnolence  passing  into  stupor,  without  continuous 
normal  sleep,  dreams,  illusions,  and  sudden  startings  in  the  sleep,  occur 
from  time  to  time.  On  ophthalmoscopic  examination,  there  are  ascer- 
tained to  be  an  enlargement  of  the  retinal  veins,  more  or  less  swelling 
of  the  optic  disk,  and  vessels  before  invisible  come  into  view.  When 
the  congestion  of  the  brain  is  of  the  passive  variety,  the  retinal  veins  are 
unduly  enlarged  and  tortuous.  Observations  on  the  drum  membrane 
disclose  increased  vascularity  of  this  organ,  which  has  intimate  con- 
nection with  the  intra-cranial  circulation.  The  superficial  temperature 
of  the  head  is  elevated  in  active  hypersemia,  but  is  not  affected  in  the 


492  DISEASES   OF   THE   NERVOUS   SYSTEM. 

passive  form.  Surface  thermometers  and  Lombard's  thermo-electric 
pile  are  employed  to  ascertain  the  temperature  of  the  scalp.  In  any 
case  there  will  be  but  slight  rise  of  the  thermometer  ;  hence,  any  con- 
siderable elevation  should  awaken  suspicion  of  inflammatory  action. 

Course,  Duration,  and  Termination. — The  light  form  may  terminate 
in  a  few  hours  or  days,  under  appropriate  treatment,  to  recur  from  time 
to  time,  it  may  be  ;  or  it  may  continue  with  fluctuations  in  the  severity 
of  the  symptoms  for  months  and  years.  A  cure  readily  results,  if  the 
causes  cease  to  operate  and  the  right  management  is  instituted.  If 
the  hypersemia  continue,  other  morbid  conditions  will  arise  out  of  it. 
The  severe  form  has  a  variable  duration.  A  cure  may  be  effected  if 
right  treatment  is  instituted  early  enough,  but  structural  alterations  will 
not  be  long  delayed,  and  mental  derangement  will  occur  at  an  early 
period,  or  a  cerebral  haemorrhage  may  take  place.  The  apoplectiform 
variety  may  terminate  in  health  or  in  cerebral  haemorrhage,  according 
to  the  method  pursued  and  the  nature  of  the  causes.  Attacks  of  this 
nature  may  precede  cerebral  hgemorrhage,  as  the  author  has  several 
times  witnessed,  but  they  are  not  often  repeated  until  the  haemorrhage 
takes  place.  The  passive  form  pursues  the  fortunes  of  the  lesions 
causing  it,  and  hence  the  duration  is  very  variable  and  the  course  pro- 
tracted. 

Diagnosis. — The  symptoms  being  due  to  disturbances  of  the  intra- 
cranial circulation,  the  diagnosis  rests  on  the  absence  of  symptoms  in- 
dicating structural  lesions — notably  the  absence  of  fever,  the  wide- 
spread bilateral  diffusion  of  the  symptoms,  and  the  fugitive  character 
of  the  attacks.  It  may  be  confounded  with  delirium  tremens,  epilepsy, 
apoplexy,  stomachal  vertigo,  etc.  As  respects  delirium  tremens,  the 
distinction  rests  on  the  habits,  the  previous  history,  and  the  severity 
and  persistence  of  the  symptoms  in  this  disease.  The  attack  of  epi- 
lepsy is  preceded  by  a  cry ;  then  come  pallor  of  the  face,  stertorous 
breathing  from  tetanic  fixation  of  the  muscles  of  respiration,  cyanosis, 
and  general  convulsions.  Children  with  congestion  of  the  brain  may 
have  such  convulsions  as  a  symptom,  but  the  history  preceding  and 
succeeding  is  very  different  in  the  two  maladies.  The  apoplectic  form 
is  distinguished  from  apoplexy  hj  the  persistence  of  the  reflex  move- 
ments, by  the  absence  of  conjugate  deviation  of  the  eyes,  and  by  the 
early  recovery  without  hemiplegia.  Stomachal  vertigo  is  preceded  by 
attacks  of  indigestion,  and  is  accompanied  by  the  conditions  of  syncope 
and  anaemia,  instead  of  hyperaemia. 

Treatment. — Causes  of  the  hyperaemia  should  cease,  if  possible. 
If  it  be  the  active  form,  the  head  should  be  elevated  and  cold  applied, 
the  feet  being  immersed  in  hot  mustard-water.  To  withdraw  tempo- 
rarily from  the  circulation  some  of  the  blood,  a  ligature  should  be  ap- 
plied around  the  thigh  or  thighs  for  a  time,  alternating  the  application 
of  the  ligature  to  prevent  injury.     Leeches  may  also  be  applied  to  the 


CEREBRAL   ANyEMIA.  493 

mastoid  process,  or  cups  to  the  neck.  In  the  apoplectiform  variety 
venesection  is  advisable,  as  this  is  the  most  expeditious  means  of  dimin- 
ishing the  intra-cranial  blood-pressuve.  A  brisk  purgative  is  also  an 
excellent  expedient,  I'elieving  by  acting  as  a  derivative  and  by  lessen- 
ing vascular  tension.  The  intra-cranial  blood-pressure  can  also  be  low- 
ered by  the  exhibition  of  veratrum  viride,  aconite,  bromide  of  potas- 
sium, ergot,  etc.  These  remedies  are  sufficient  in  the  light  foi-m,  but 
in  the  severe  form  a  combination  of  the  various  means  of  treatment 
will  be  necessary.  The  treatment  of  the  passive  form  is  a  part  of  the 
treatment  required  in  the  condition  producing  the  hypersemia,  and  need 
not  now  be  discussed.  The  strictest  attention  must  be  paid  to  the 
diet  and  mode  of  life.  An  abstemious  life — the  diet  consisting  of 
fruit  and  vegetables  chiefly — and  early  hours  and  the  avoidance  of  all 
forms  of  excitement  have  prolonged  life  for  many  years,  when  an  early 
demise  was  threatened  by  cerebral  hypersemia.  Especially  should 
alcoholic  stimulants  and  the  powerful  emotions  excited  by  speculations 
of  all  kinds  be  avoided.  Such  mild  stimulants  as  tea  and  coffee  even 
should  be  abandoned.  In  making  these  suggestions  the  author  wishes 
his  readers  to  note  that  he  regards  protracted  rest  to  the  mind  as  often 
injurious,  and  that  light  mental  occupation  is  preferable  to  an  entire 
disuse  of  the  faculties. 


CEREBRAL   AN.E:MIA. 

Definition. — By  cerebral  anmmia  is  meant  a  lessened  amount  of 
blood  in  the  brain.  It  may  be  general  or  partial:  in  the  former  the 
diminished  supply  of  blood  affects  the  whole  organ  ;  in  the  latter  a 
particular  district  is  deprived  of  its  blood  by  the  occlusion  of  a  vessel. 
It  is  the  general  form  of  cerebral  anjemia  to  be  considered  here. 

Causes. — The  most  perfect  type  of  cerebral  anaemia  is  that  produced 
by  large  loss  of  blood.  Our  knowledge  of  this  condition  has  been  ren- 
dered the  more  accurate  by  the  experimental  study  of  the  subject  in  ani- 
mals.* The  effects  of  loss  of  blood  on  the  functions  of  the  brain  are 
seen  after  severe  haemorrhage,  as  jpost-partxnin  haemorrhage,  unavoid- 
able haemorrhage,  menorrhagia,  metrorrhagia,  etc.  Chronic  wasting 
diseases,  by  the  constant  losses  of  nutrient  material,  induce  cerebral 
anaemia.  Phthisis,  chronic  dysentery,  suppuration,  and  prolonged  lac- 
tation, belong  to  this  category.  Maladies  which  impair  the  power  to 
produce  nutrient  material,  affecting  the  primary  and  secondary  assimila- 
tion, will  also  cause  anaemia  of  the  brain.  To  this  state  as  it  occurs  in 
infants  was  applied  the  term  hydrocephaloid  by  Marshall  Hall,  who 
first  demonstrated  the  important  fact  that  a  condition  supposed  to  be 
due  to  inflammation  was  really  the  product  of  anaemia.  Under  the 
influence  of  shock,  by  powerful  mental  or  moral  emotions,  a  sudden 
*  Kussmaul  and  Tenner,  "  Sydenham  Society's  Translation." 


494  DISEASES   OF   THE   NERVOUS   SYSTEM. 

contraction  of  tlie  intra-cranial  vessels  occurs,  and  syncope,  with  loss 
of  consciousness,  ensues.  Feebleness  of  the  heart  induces  angemia  of 
the  brain — a  fact  well  exemplified  in  the  sudden  pallor  and  faintness 
experienced  by  convalescents  on  rising  up  after  long  decubitus  ;  also 
in  the  case  of  those  who  suffer  from  weak  heart,  fatty  heart,  or  ob- 
struction at  the  aortic  orifice,  etc. 

Pathological  Anatomy. — The  morbid  changes  are  very  simple. 
The  amount  of  blood  is  below  the  normal,  and  the  vessels  are  less 
full.  The  appearance  of  the  brain  is  pale  and  exsanguine,  and  on 
transverse  section  of  the  hemispheres  there  are  no  bloody  points. 
The  subarachnoid  spaces  and  the  ventricles  contain  a  good  deal  of 
fluid,  and  the  perivascular  lymph-spaces  are  also  well  filled  with  fluid, 
for,  as  the  vessels  contain  less  blood,  the  cerebro-spinal  fluid  increases  ; 
while  in  hypergemia  the  distention  of  the  vessels  forces  the  fluid  out, 
closes  the  lymph-spaces,  and  flattens  the  convolutions.  The  opposite 
state  obtains  in  anaemia  :  the  brain  is  pale,  white,  and  moist ;  the  ves- 
sels small,  the  lymph-spaces  large.  In  partial  anaemia,  other  factors 
are  concerned,  and  hence  the  local  conditions  differ. 

Symptoms. — There  are  two  distinct  forms  :  acute,  or  sudden  ; 
chronic,  or  light.  Venesection  ad  deliquum  animi  furnishes  a  com- 
plete picture  of  the  first :  the  face  grows  deadly  pale,  the  lips  white, 
the  pupils  dilate,  the  action  of  the  heart  becomes  very  feeble,  the  pulse 
small,  a  cold  sweat  breaks  out  over  the  body,  ringing  noises  sound  in 
the  ears,  surrounding  objects  appear  dim,  and  a  mist  gathers  before 
the  eyes  ;  voices  are  heard  in  the  distance,  and  the  words  are  unintel- 
ligible, everjrthing  fades  suddenly  out  of  consciousness,  and  the  patient 
falls  as  if  lifeless,  respiration  having  ceased,  and  the  heat-beart  scarcely 
continuing.  There  is  complete  muscular  resolution,  but  in  an  instant 
the  eyelids  begin  to  tremble,  the  muscles  of  the  lips  and  face  twitch, 
and  a  general  convulsion  follows.  The  syncope,  which  is  merely  a 
fainting-fit,  does  not  proceed  any  further  than  suspension  of  conscious- 
ness, and  in  a  short  time  the  respiration  begins,  the  heart-beat  grows 
stronger,  the  patient  opens  his  eyes,  looks  around  with  a  dazed  expres- 
sion, and  asks  what  has  happened  ;  he  tries  to  get  up,  and  finds  him- 
self very  weak,  but  in  a  short  time  the  bodily  vigor  is  entirely  restored. 
The  convulsions  of  cerebral  anaemia  are  due  to  two  factors  :  to  an  ab- 
normal excitability  of  the  "  spasm-center  "  ;  to  the  circulation  of  black 
blood  through  this  spasm-center.  In  the  slow,  habitual,  or  chronic 
anaemia,  the  condition  is  that  of  depression  of  function.  The  brain, 
inadequately  supplied  with  nutrient  material,  functionates  imperfectly  ; 
the  special  senses  are  both  irritable  and  depressed — the  sight  is  dull 
(amblyopia),  and  light  is  painful  to  the  eyes  ;  hearing  is  obtuse,  there 
are  subjective  noises  in  the  ears,  tinnitus,  etc.,  and  loud  sounds  are 
distressing  ;  the  mental  operations  are  slow  and  confused,  and  there 
may  be  illusions,  hallucinations,  maniacal  excitement,  etc.  (puerperal 


CEREBRAL   ANEMIA.  495 

mania,  insanity  of  lactation,  etc.)  ;  muscular  movements  are  excited, 
or  depressed  and  feeble,  tremulous  or  incoordinate  ;  the  sensory  func- 
tions are  similarly  affected — there  may  be  excitement  or  depression, 
neuralgic  pains,  numbness,  prickling,  tingling,  or  anoBsthesia  ;  vertigo 
is  nearly  always  present,  and  consequent  uncertainty  of  movements  ; 
headache  is  also  commonly  present,  and  may  be  a  sense  of  heaviness 
or  oppression,  or,  more  frequently,  acute  pain  ;  exertion  causes  great 
fatigue,  and  syncopal  attacks  are  easily  induced  ;  the  action  of  the 
heart  is  weak,  and  rapid  action  is  excited  by  the  least  movement ; 
and  the  sense  of  f  aintness  is  usually  accompanied  by  nausea.  In  the 
form  of  cerebral  anaemia,  known  as  hydrocephaloid,  the  child  is  ex- 
hausted by  a  wasting  malady  ;  its  surface  is  cool,  skin  pale,  the  pulse 
quick  and  weak,  the  eyes  are  half  closed,  sunken,  and  surrounded  by 
broad,  dark  areolae,  the  fontanelle  is  concave,  the  head  cool ;  there  is 
much  fretfulness,  although  there  is  a  somnolent  state  ;  the  stomach 
is  irritable,  the  bowels  relaxed. 

Course,  Duration,  and  Termination. — The  acute  form,  so  far  as  the 
immediate  attack  is  concerned,  lasts  a  few  minutes  only,  but  this  is 
merely  a  symptom  of  a  long-established  anaemia  of  the  brain.  The 
chronic  form  has  an  indefinite  duration,  and  pui'sues  a  varying  course 
according  to  the  management  and  the  nature  of  the  causes.  The 
termination  is  usually  in  restoration  to  the  normal  state,  if  the  treat- 
ment be  suitable.  So  important  are  the  changes  in  the  vessel-walls  in 
anaemia,  that  we  should  not  overlook  the  gravity  of  any  case  that  has 
continued  a  long  time.  Furthermore,  as  various  intercurrent  maladies 
may  develop,  prognostic  opinions  should  be  expressed  with  caution  if 
the  anaemia  has  persisted. 

Diagnosis. — As  cerebral  hypersemia  presents  many  symptoms  in 
common  with  cerebral  anaemia,  the  diagnosis  of  these  affections  may 
be  confused,  but  attention  to  a  few  points  ought  to  conduct  to  right 
conclusions.  The  history  of  the  causes,  the  appearances  of  ansemia, 
and  the  depression  of  the  circulation,  will  indicate  the  nature  of  the 
case.  The  use  of  the  surface  thermometer,  or  thermo-electric  pile,  to 
ascertain  the  temperature  of  the  scalp,  is  necessary,  for  in  anaemia  the 
temperature  is  rather  below  than  above  normal,  but  in  hyperaemia  the 
opposite  condition  obtains.  Ophthalmoscopic  inspection  of  the  retina 
and  otoscopic  inspection  of  the  drum  membrane  should  be  made,  to 
ascertain  the  character  of  the  circulation  :  in  hyperaemia  the  retinal 
vessels  are  abnormally  full  and  the  drum  is  red  and  injected,  whereas 
in  anaemia  the  retina  and  drum  membrane  are  pale  and  comparatively 
bloodless. 

Treatment. — The  recumbent  posture  and  stimulation  ot  the  nares 
with  ammonia  are  the  only  measures  necessary  in  the  treatment  of 
syncope.  When  alarming  depression  is  due  to  haemorrhage,  besides 
the  measures  necessary  to  stop  the  loss  of  blood,  anaemia  of  the  brain 


496  •    DISEASES   OF   THE   NERVOUS   SYSTEM. 

is  to  be  overcome  by  depression  of  the  head  and  elevation  of  the 
limbs,  by  the  administration  of  alcoholic  stimulants,  by  the  subcutane- 
ous injection  of  stimulants,  by  the  intravenous  injection  of  ammonia, 
and  by  transfusion.  The  chronic  form  of  cerebral  ansemia  is  to  be 
arrested  by  stopping  the  sources  of  waste,  by  the  use  of  iron  and  the 
phosphates,  and  by  judicious  alimentation.  The  best  results  are  ob- 
tained by  the  administration  of  a  stimulant  to  the  cerebro-spinal  axis 
(strychnia)  and  a  chalybeate  tonic.  Arsenic  is  often  highly  service- 
able in  cerebral  ansemia,  in  combination  with  iron.  For  the  maniacal 
delirium  of  cerebral  anaemia,  the  hypodermatic  injection  of  morphia  is 
of  the  greatest  value.  When  there  is  associated  with  this  delirium 
a  high  degree  of  motor  excitement,  atropia  or  duboisia  should  be  com- 
bined with  the  morphia. 


OCCLUSION   OF   THE   CEREBRAL  VESSELS. 

Definition. — Under  this  term  are  included  all  lesions  which  occlude 
or  block  the  vessels,  thus  causing  ansemia  of  some  part  or  parts  of  the 
brain.  The  occlusion  may  occur  in  a  cerebral  vessel,  or  may  be  pro- 
duced by  an  embolism  conveyed  thither  from  any  part  of  the  vascular 
system.  Under  this  term  must  be  comprised  the  remote  as  well  as  the 
immediate  results  of  occlusion. 

Causes. — The  factors  chiefly  concerned  in  the  occlusion  of  intra- 
cranial vessels  are  thrombosis  and  embolism.  Chronic  endarteritis  and 
slowing  with  weakening  of  the  blood-current  are  the  causes  of  throm- 
bosis. The  changes  in  the  arterial  tunics  consist  in  atheromatous  and 
calcareous  degeneration  ;  the  lumen  of  the  vessel  is  gradually  narrowed 
by  the  deposition  of  new  material,  and  the  intima  is  roughened.  The 
propulsion  of  the  blood  is  hindered  by  weakness  of  the  heart's  action, 
and  by  diminished  elasticity  of  the  walls  of  the  arteries,  due  to  the 
atheromatous  changes  in  the  tunics.  When  the  disease  in  the  walls 
of  a  cerebral  vessel  reaches  a  certain  point,  coagulation  of  the  blood 
takes  place  and  an  occlusion  {autochthonous  thrombosis)  is  thus  effect- 
ed. The  formation  of  a  thrombus  is  also  favored  by  the  condition  of 
the  blood  itself.  In  chronic  wasting  diseases,  the  relative  proportion 
of  fibrin  in  the  blood  being  much  increased,  coagulation  is  promoted 
accordingly.  An  autochthonous  thrombus  may  form  in  a  vessel  whose 
lumen  had  been  obstructed  by  the  pressure  of  a  tumor. 

Emboli  consist  of  bits  of  fibrin,  exudations,  or  concretions,  which, 
formed  at  some  distant  point  and  carried  into  the  circulation,  are 
deposited  in  the  brain.  The  most  usual  source  of  emboli  is  endocar- 
ditis, either  of  the  ulcerative  variety  or  of  the  chronic  form  with  its 
polyp-like  excrescences,  or  fibrin  vegetations.  According  to  the  ob- 
servations of  Bertin,  the  emboli  come  from  the  left  auricle,  four  times  ; 
from  the  left  ventricle,   twelve  times  ;   from   the    aortic  valves,  ten 


OCCLUSION   OF   THE   CEREBRAL   VESSELS.  497 

times  ;  from  the  mitral,  twenty-four  times.  These  figures  agree  with 
the  usual  experience  on  this  point.  Cardiac  emboli  are  also  produced 
in  the  following  way  :  clots  form,  especially  in  the  auricle,  when  the 
heart  is  weakened  by  myocarditis,  fatty  degeneration,  uncompensated 
valvular  lesions,  and  such  chronic  wasting  diseases  as  cancer  and  tu- 
berculosis. Such  clots,  subsequently  pulverized  by  the  cardiac  move- 
ments, are  carried  into  the  circulation.  Emboli  may  also  be  derived 
from  aortic  aneurism,  from  syphiloma  of  the  great  vessels,  etc. 

Pathological  Anatomy. — Owing  to  its  position  at  or  near  the  summit 
of  the  arch  of  the  aorta,  the  blood-current  from  the  aortic  orifice  is  di- 
rected to  the  left  common  carotid,  so  that  an  embolus  loosened  from 
the  heart  naturally  enters  this  vessel,  and  its  prolongation  within  the 
cranium,  the  Sylvian  artery.  It  necessarily  follows  from  this  that  the 
left  side  is  usually  obstructed.  It  rarely  happens  that  an  embolus  en- 
ters the  vertebral  arteries.  Sometimes  the  embolisms  are  multiple,  and 
enter  the  vessels  on  both  sides,  or  are  lodged  in  different  places  on  the 
left  side.  As  certain  vessels  are  usually  occluded,  it  is  important  to 
have  a  clear  understanding  of  the  parts  supplied  by  them.  The  left 
Sylvian  artery  sends  branches  to  the  second  and  third  frontal  convolu- 
tions, the  anterior  and  superior  portions  of  the  three  temporal  convolu- 
tions, the  island  of  Reil,  the  parietal  convolutions,  part  of  the  external 
and  all  of  the  internal  capsule,  the  lenticular  nucleus,  and  most  of  the 
corpus  striatum.  It  is  important  to  note,  further,  that  the  vessels  of 
this  part  of  the  brain  have  the  arrangement  of  Cohnheim's  terminal 
arteries — arteries  without  anastomoses — while  the  vessels  of  the  gray 
matter  of  the  hemispheres,  or  the  cortex,  communicate  freely  with 
each  other.*  When  an  artery  of  the  "basal  system"  is  obstructed 
either  by  a  thrombus  or  embolism,  an  anaemia  of  the  territory  sup- 
plied by  the  vessel  at  once  ensues — either  a  simple  anaemia  and  white 
softening,  or  anaemia  followed  by  collateral  hyperasmia  and  oedema. 
The  simple  anaemia  and  white  or  yellowish-white  softening  occur 
when  the  blood  in  the  whole  extent  of  the  occluded  vessel  coagulat- 
ing, prevents  the  backward  flow  of  blood  through  the  capillaries,  and 
thus  obviates  the  collateral  hyperaemia  and  oedema.  The  anaemic  tis- 
sue dies  or  undergoes  necrobiosis  in  consequence  of  the  loss  of  its  en- 
tire nutritive  supply.  The  nerve-tissue  elements  become  disassociated, 
break  up  into  a  diffluent  granular  mass,  and  are  crowded  with  fat-cells, 
whence  the  color  of  the  softened  tissues  assumes  a  somewhat  yellowish 
aspect.  Yellow  softening  is  also  a  stage  of  the  next  form.  When  a 
terminal  artery  is  occluded,  and  all  parts  of  the  vessel  beyond  the  seat 
of  obstruction  remain  pervious,  blood  flows  back  through  the  capilla- 
ries from  the  nearest  artery  and  vein,  until  the  previously  angemic  and 
bloodless  district  is  deeply  engorged.     Changes  now  occur  in  the  walls 

*  The  reader  should  pcrnsc  in  this  connection  the  articles  on  "  Arteritis  "  and  on 
"  Thrombosis  and  Embolism." 
32 


498  DISEASES   OF   THE   NERVOUS   SYSTEM. 

of  the  vessels,  permitting  diapedeses  of  the  red-blood  globules.  As,  in 
the  process  of  softening  and  disintegration  which  now  ensues,  the  tis- 
sues are  colored  by  the  red  corpuscles,  the  appearances  are  entitled 
"  red  softening."  Minute  extravasations  occur  here  and  there,  from 
rupture  of  capillaries,  and  hence,  in  the  midst  of  a  uniform  red  there 
will  be  seen  the  dark  points  of  "  capillary  apoplexy."  These  extrava- 
sations may  be  so  numerous  as  to  present  the  appearance  of  a  cerebral 
haemorrhage.  In  from  two  to  four  weeks  the  red  softening  becomes 
yellow  softening  in  consequence  of  the  transformation  of  the  haemo- 
globulin  and  the  fatty  degeneration  of  the  nerve-elements.  The  soft- 
ening proceeding  to  another  stage  becomes  "  white  softening,"  when 
there  is  a  milky,  or  rather  creamy  fluid,  containing,  mixed  with  it, 
masses  or  particles  of  broken-down  nerve-elements.  There  is  no  abrupt 
line  of  demarkation,  but  the  diseased  part  shades  off  into  the  surround- 
ing healthy  part  by  a  fine  gradation. 

Symptoms. — There  are  two  well-defined  modes  of  onset :  the  grad- 
ual, which  occurs  to  thrombosis  ;  the  sudden,  or  apoplectic,  due  to 
embolism.  The  first  form,  or  thrombosis,  is  a  malady  of  the  old  ;  the 
second  form,  or  embolism,  may  occur  at  any  period,  frequently  in  the 
young.  As,  when  chronic  arteritis  of  the  cerebral  vessels  exists,  a  num- 
ber of  them  may  be  diseased  at  the  same  time,  the  resulting  symptoms 
must  necessarily  be  widely  diffused,  and,  as  the  disease  has  proceeded 
to  different  stages  at  different  points,  there  may  be  present,  at  the  same 
time,  the  symptoms  of  excitation  and  depression  of  function.  Head- 
ache, more  or  less  persistent,  and  of  variable  intensity,  is  the  earliest 
symptom  ;  next,  alterations  of  character  become  evident — the  indi- 
vidual grows  irritable,  morose,  and  despondent,  his  mind  is  easily 
fatigued,  and  memory  is  impaired  ;  at  first  names,  then  some  unusual 
word,  ultimately  most  words,  are  forgotten.  Occasionally  the  only 
mental  defect  observed  is  loss  of  the  memory  for  words — amnesia  of 
verbal  language — which  may  occur  slowly  or  suddenly,  with  or  with- 
out something  of  a  stroke.  After  the  headache,  vertigo  comes  on,  and 
may  be  occasional  and  caused  by  a  change  of  posture,  or  it  may  be 
constant  when  sitting  up  and  when  recumbent.  Difficulty  of  locomo- 
tion is  experienced,  in  consequence  partly  of  the  vertigo,  but  chiefly 
because  of  weakness  of  a  group  of  muscles  or  of  a  member  ;  more  or 
less  of  senile  trembling  may  be  present,  or  the  trembling  of  muscular 
weakness  ;  and  the  movements  of  the  tongue  may  be  imperfect  and 
speech  hesitating  and  mumbling.  There  are  two  causes  for  the  symp- 
toms just  detailed — gradual  encroachment  on  the  lumen  of  diseased 
vessels,  whence  the  blood-stream  is  lessened,  and  interference  with 
the  nutrition  of  the  brain  by  reason  of  calcareous  degeneration  of  the 
capillaries.  The  next  point  in  the  morbid  complexus  is  the  occurrence 
of  a  sudden  attack,  which  may  or  may  not  be  apoplectic.  If  apoplec- 
tic, the  patient  falls  suddenly  into  a  condition  of  insensibility,  with 


OCCLUSION   OF   THE   CEREBRAL   VESSELS.  499 

complete  muscular  resolution.  On  emerging  from  such  an  attack 
there  may  be  hemiplegia  ;  if  right  hemiplegia,  associated  with  more 
or  less  disability  of  speech,  possibly  with  aphasia.  In  other  cases, 
with  equal  suddenness,  but  without  any  apoplectic  seizure,  there  may 
occur  a  hemiplegia,  or  the  paralysis  may  be  limited  to  the  arm,  or  to 
the  leg,  or  to  the  face  ;  it  may  be  complete  or  partial  (paresis),  and 
Avith  weakness  there  may  be  contractions  and  rigidity.  The  paralysis 
may  disappear  quickly,  and  after  an  uncertain  jjeriod  may  occur  again, 
or  be  succeeded  by  rigidity  and  contraction.  The  disappearance  of  a 
paralysis  under  these  circumstances  means  the  reopening  of  the  ob- 
structed area  to  the  circulation  by  collateral  channels  or  anastomoses 
— a  condition  of  things  only  possible  in  the  cortex.  An  autochthonous 
thrombus  may  form  in  a  vessel  of  the  basal  system.  The  final  occlu- 
sion of  the  vessel  may  be  preceded  by  various  prodromata — by  head- 
aches, vertiginous  sensations,  numbness,  tingling,  formication,  cold- 
ness, muscular  cramps,  etc.  Paralysis  may  develop  slowly,  as  the 
thrombus  slowly  forms,  or  suddenly,  with  the  usual  phenomena  of 
the  apoplectic  stroke  ;  the  paralysis  is  strictly  localized  and  does  not 
change,  for,  the  vessels  being  of  the  terminal  kind,  collateral  hyperse- 
mia  and  cedema  result,  and  the  affected  tissue  goes  through  the  pro- 
cess of  necrobiosis.  When  occlusion  occurs  in  this  way,  the  subse- 
quent phenomena  are  the  same  as  those  of  embolism.  As  the  embolus 
causing  the  cerebral  mischief  comes  from  some  distant  point  in  the 
vascular  system,  it  is  obvious  that  there  can  be  no  intra-cranial  disor- 
ders produced  by  it  ere  it  effects  a  lodgment  in  the  brain.  It  is  evi- 
dent that  there  must  be  very  considerable  variation  in  the  severity  of 
the  symptoms,  according  to  the  importance  and  the  situation  of  the 
vessel  occluded.  In  a  majority  of  cases  the  attack  is  apoplectic — 
there  may  be  for  an  instant  intense  headache  and  dizziness,  sudden 
flush  or  pallor  of  the  face,  or  the  patient  may  utter  a  wild  cry — he 
falls  immediately  into  unconsciousness,  with  complete  muscular  reso- 
lution, or  there  may  be  a  distinct  epileptiform  seizure.  Instead  of  un- 
consciousness, the  stroke  may  be  nothing  more  than  a  severe  vertigo, 
with  confusion  of  mind,  muscular  twitchings  on  the  affected  side,  and 
vomiting.  Vomiting  may  also  occur  in  the  apoplectic  form,  just  as  the 
mental  confusion  is  coming  on.  On  recovering  from  the  stroke  or 
shock — which  is  doubtless  due  to  the  suddenly  produced  partial  anae- 
mia, effecting  at  the  same  moment  an  immense  change  in  the  intra-cra- 
nial blood-pressure — a  hemiplegia  is  found  to  exist,  and  it  is  most  fre- 
quently of  the  right  side,  owing  to  the  arrangement  of  the  vessels  on 
the  left  side  of  the  brain.  Although  right  hemiplegia  is  usual,  it  is 
not  invariable  :  there  may  be  left  hemiplegia,  or  bilateral  paralysis,  or 
paralysis  of  the  different  cranial  nerves.  Embolism  may  also  affect 
the  central  artery  of  the  retina,  and  amaurosis  result  from  the  occlu- 
sion.    Double  optic  neuritis  arises  during  the  course  of  all  "coarse 


500  DISEASES   or   THE   NERVOUS   SYSTEM. 

organic  lesions  "  of  the  brain,  and  hence  ophthalmoscopic  examination 
is  a  necessary  duty  in  such  cases.  The  mental  functions  are  variously 
affected.  In  the  slow  form  of  occlusion — thrombosis  from  chronic 
endarteritis — there  is  gradual  mental  failure,  beginning  in  loss  of 
memory,  and  thence  the  spectacle  of  senile  dementia.  In  embolism 
the  mental  faculties  are,  during  the  period  of  coma,  entirely  sus- 
pended ;  if  the  patient  emerge  from  this  with  hemiplegia,  the  mind  is 
always  enfeebled  to  a  greater  or  less  extent,  the  language  faculty  is 
variously  impaired,  the  emotional  nature  is  highly  excited,  and  the 
reason  and  judgment  are  clouded.  With  right  hemiplegia  from  em- 
bolism there  is  usually  associated  aphasia,  or  loss  or  impairment  of 
the  faculty  of  communicating  ideas  by  words  or  by  signs.  The  hemi- 
plegia involves  the  tongue  and  the  corresponding  side  of  the  face. 
The  reflex  movements  are  readily  excited  in  the  paralyzed  parts. 
When  there  is  embolic  obstruction  of  the  basilar  artery,  the  sym^jtoms 
differ  somewhat  from  the  description  above  given.  The  hemispheres 
are  not  involved,  nor  the  important  parts  supplied  by  the  Sylvian 
artery  ;  there  is  no  apoplectic  seizure,  nor  loss  of  consciousness,  nor 
troubles  of  the  intellectual  faculties.  There  are  disorders  in  vocal 
expression,  due  to  paralysis  or  ataxia  of  the  muscles  of  the  tongue 
(ataxic  aphasia),  but  vertigo  and  vomiting  are  usual  symptoms. 

Course,  Duration,  and  Termination.— The  course  of  symptoms  refer- 
able to  the  changes  preceding  and  resulting  in  thrombosis  is  essentially 
chronic.  Months  and  years  may  be  occupied  in  reaching  the  point  of 
coagulation,  and  other  months,  even  years,  may  be  passed  in  the  para- 
lytic state.  When  the  lesions  are  of  the  basal  system  they  are  per- 
manent. Although  there  may  be  some  improvement,  which,  however, 
does  not  continue,  the  members  paralyzed  remain  in  the  condition  at 
which  they  had  arrived  after  several  months.  In  thromboses  the  most 
sudden  and  considerable  improvement  takes  place  in  paralysis  of  mem- 
bers, defects  of  speech,  and  disorders  of  sensations,  due  to  disease  of 
the  vessels  of  the  cortex  ;  but  the  probability  of  the  return  of  these 
lesions,  or  of  the  appearance  of  other  lesions,  should  not  be  forgotten. 
While  the  prospect  of  great  immediate  improvement  is  good  in  such 
cases,  the  future  must  be  regarded  with  apprehension.  On  the  other 
hand,  in  embolic  occlusion,  the  immediate  results  are  more  severe. 
Death  may  be  the  result  of  the  occlusion  of  a  large  vessel  within  two 
or  three  days,  or  longer,  the  patient  never  emerging  from  the  coma. 
In  other  cases  the  patient  arouses  from  the  coma,  hemiplegia  exists 
with  aphasia,  the  temperature  rises  a  little  as  the  collateral  hypersemia 
and  oedema  come  on,  but  falls  again  in  a  few  .days,  and  the  case  then 
pursues  the  usual  course  of  localized  softening  from  any  cause.  Right 
hemiplegia  and  aphasia,  from  blocking  of  the  left  middle  cerebral,  may 
occur  in  youth,  early  manhood,  at  any  period  in  fact,  and  are  associated 
with  valvular  disease  of  rheumatic  origin.     These  lesions  may  also  be 


OBLITERATION   OF   THE   CAPILLARIES.  501 

associated  with  aneurism,  with  syphiloma,  or  with  ulcerative  endocar- 
ditis. 

Diagnosis. — The  diagnosis  of  thrombosis  rests  on  the  evidence  of 
chronic  arteritis — the  simultaneous  presence  of  the  changes  in  the 
radial,  the  color  of  the  hair,  the  condition  of  the  skin,  an  arcus  senilis  ; 
on  the  variability  and  diffusion  of  the  prodromal  signs,  and  those  of 
the  established  lesions.  Embolism  is  known  by  the  age  of  the  subject 
(often  so  at  least),  by  the  history  of  rheumatism,  the  existence  of  val- 
vular lesions,  by  the  suddenness  of  onset  without  prodromes. 

Treatment. — The  author  has  had  remarkable  results  from  the  follow- 
ing plan  of  treatment  in  thrombosis  :  Carbonate  and  iodide  of  ammo- 
nium (ten  grains  of  the  former  and  five  grains  of  the  latter)  are  given 
three  times  a  day  in  a  suitable  vehicle,  for  several  months,  usually,  the 
object  being  dual — to  increase  the  action  of  the  heart  and  arteries,  and 
to  effect  a  solution  of  thrombi  forming  by  maintaining  the  alkalinity 
of  the  blood.  To  postpone  and  possibly  arrest  the  atheromatous  de- 
generation of  the  vessels,  cod-liver  oil  and  the  sirup  of  the  lactophos- 
phate  of  lime  are  regularly  exhibited  (a  teaspoonful  of  each)  three 
times  a  day,  immediately  after  meals.  The  ammonia  solution  is  ad- 
ministered before  meals.  At  the  same  time  these  remedies  are  being 
given,  a  daily  dose  (at  10  a.  m.)  of  quinia  (five  to  ten  grains)  is  also 
prescribed,  should  there  be  a  condition  of  depression  and  languor  of 
the  intracranial  circulation  requiring  it,  but  the  carbonate  of  ammonia 
is  usually  sufiicient.  With  this  plan  is  conjoined  a  suitable  regimen — 
a  simple  but  nutritious  diet,  moderate  exercise,  and  careful  supervision 
of  the  various  excreta.  As  soon  as  possible  after  an  embolic  obstruc- 
tion has  occurred,  carbonate  of  ammonia  should  be  given — very  useful- 
ly in  the  liquor  ammonii  acetatis — and  should  be  kept  up  for  weeks. 
The  most  absolute  rest  should  be  maintained,  and  the  diet  should  be 
light  and  unstimulating.  In  a  m.onth  or  two  a  very  light  galvanic 
current  (from  two  cups)  may  be  passed  through  the  brain  in  both 
directions.  Quinia  is  most  useful,  especially  if  there  be  any  elevation 
of  temperature  ;  but  in  all  cases  it  has  seemed  to  the  author  highly 
useful  after  some  weeks'  administration  of  ammonium  carbonate. 


OBLITERATION  OF  THE   CEREBRAL   CAPILLARIES. 

Pathogeny. — The  capillaries  of  the  brain  are  occluded  by  the  finer 
particles  which  readily  pass  through  the  larger  vessels.  In  the  severer 
forms  of  acute  malarial  poisoning  small  particles  of  pigment  are  formed, 
and,  entering  the  cerebral  capillaries,  lodge,  and  are  known  as  "pigment 
emholismsP  Violent  delirium,  terminating  in  coma,  and  sometimes 
convulsions,  may  result  from  the  occlusions  formed  in  this  way.  The 
white-blood  corpuscles,  under  conditions  not  now  understood,  aggre- 
gate in  masses  and  form  emboli.     These  are  probably  examples  of 


502  DISEASES   OF  THE   NERVOUS   SYSTEM. 

pyemic  change,  for  such  emboli  have  been  formed  in  connection  with 
pysemia,  erysipelas  of  the  face,  etc.  Emboli,  consisting  of  particles  of 
cancerous,  septic,  or  decomposing  material — infective  emboli — may  also 
be  minute  enough  to  pass  the  larger  vessels  and  occlude  the  cerebral 
capillaries.  In  very  rare  cases  the  capillaries  are  blocked  by  lime  salts, 
taken  up  at  some  point  where  disintegration  of  bone  is  going  on — 
lime-salts  emboli.  Again,  emboli  consist  of  fat-globules  which  enter 
the  blood  from  the  marrow  of  fractured  hones,— fat  emboli.  The  capil- 
laries of  the  lungs  may  arrest  them  entirely,  and  hence  the  most  serious 
symptoms  are  referable  to  these  organs  ;  but  the  finest  globules  may 
pass  through  the  lungs  and  block  some  of  the  cerebral  capillaries.  As 
the  anastomoses  between  the  capillaries  are  very  abundant,  it  is  obvious 
that  if  the  obstructions  are  but  few  in  number  they  will  be  compen- 
sated for.  When  numerous,  there  will  be  j)roduced  ansemia,  followed 
by  the  usual  changes  of  necrobiosis,  ending  in  softening. 

Symptoms. — In  the  case  of  pigment  embolisms  occurring  during  a 
malarial  fever,  the  onset  of  this  malady  is  announced  by  intense  head- 
ache, vertigo,  delirium,  sometimes  convulsions,  and  the  febrile  phe- 
nomena are  greatly  intensified.  If,  during  the  course  of  facial  erysip- 
elas, similar  symptoms  arise,  they  may  be  due  to  white-corpuscle  em- 
bolisms, or,  if  occurring  after  a  fracture  of  a  bone,  may  be  due  to  fat- 
embolisms.  When  the  embolisms  are  not  very  numerous  the  symp- 
toms may  be  less  pronounced  :  there  may  be  dizziness,  loss  of  memory, 
and  other  mental  defects,  persistent  headache,  etc.  In  any  case  the 
diagnosis  can  hardly  be  more  than  a  fortunate  guess.  The  treatment 
may  be  conducted  on  the  same  basis  as  that  of  occlusion  of  the  arteries. 


OCCLUSION  OF   THE   CEREBRAL   SINUSES. 

Pathogeny. — Thrombosis  is  the  mode  of  occlusion  of  the  cerebral 
sinuses,  and  it  may  result  from  venous  stasis  or  from  phlebitis.  In  the 
former  case  the  propelling  power  of  the  heart  is  much  reduced,  and 
the  fibrin  of  the  blood  increased  (hyperinosis).  This  condition  of  af- 
fairs occurs  chiefly  in  children  exhausted  by  long-standing  illness  ;  in 
the  cases  observed  by  the  author,  there  had  existed  an  ileo-colitis  of 
several  weeks.  The  phlebitis  is  secondary  to  some  morbid  process  in 
the  neighborhood,  most  frequently  to  caries  of  the  petrous  portion  of 
the  temporal  bone,  and  the  petrosal  or  transverse  sinus  only  may  be 
attacked,  but  the  purulent  phlebitis  extends  occasionally  to  the  cavern- 
ous sinus  and  the  circular  sinus.  Next  to  caries  of  the  bones,  the 
most  frequent  cause  of  this  form  of  thrombus  is  erysipelas  of  the  head 
and  face,  carbuncle  of  the  upper  lip  or  nose,  and  malignant  pustule  of 
the  lip.  The  position  of  the  thrombus  is  determined  by  the  natui'e  of 
the  cause  :  if  caries,  the  thrombus  is  found  in  the  transverse  or  petrosal 
or  cavernous  sinus  ;  if  erysipelas,  or  malignant  carbuncle,  in  the  ptery- 


OCCLUSION   OF   THE   CEREBRAL  SINUSES.  503 

gold  plexus  and  cavernous  sinus  ;  if  stasis  from  cardiac  feebleness  and  hy- 
perinosis,  in  the  longitudinal  sinus.  The  thrombus  and  the  subsequent 
changes  taking  place  in  it  are  the  same  as  those  already  described. 
The  vessels  entering  the  sinus,  the  seat  of  occlusion,  are  turgid,  tortu- 
ous, and  their  tunics  weakened,  so  that  they  yield  to  the  increased  pres- 
sure, and  haemorrhages  occur  at  various  points,  on  the  hemispheres, 
especially  in  the  cortex.  Softening  occurs  to  a  small  extent  about  the 
htemorrhagic  extravasations,  and  meningitis  may  arise  as  a  complication. 
Symptoms. — As  the  cases  of  thrombosis  of  the  sinuses  occur  in  the 
subjects  of  wasting  maladies,  or  of  cardiac  feebleness,  the  sjonptoms 
produced  by  the  thrombus  are  superadded  to  those  of  the  original 
malady.  The  signs  by  which  such  an  occurrence  may  be  recognized 
are  all  the  more  obscure,  since  the  anaemia  of  the  brain  may  be  accom.- 
panied  by  many  of  them.  There  have  been  observed  the  following  : 
rigidity  of  the  cervical  muscles,  the  occiput  being  buried  in  the  pillow, 
and  sometimes  general  muscular  rigidity  ;  ptosis,  strabismus,  nystagmus, 
and  paresis  of  facial  muscles  ;  hebetude  of  mind,  stupor  passing  into 
coma,  sometimes  delirium  ;  headache,  vertigo,  nausea  and  vomiting  ;  de- 
lirium, ending  in  coma  ;  contractures,  or  paresis,  local  tremor,  clonic 
convulsions  ;  paralysis  may  be  crossed  with  contractures  and  rigidity. 
Indeed,  so  various  and  diffused  are  the  symptoms  that  the  diagnosis 
must  always  be  in  the  nature  of  a  guess.  More  importance  is  to  be  at- 
tached to  circulatory  disturbances  affecting  external  vessels.  The  facial 
vein  communicates  with  the  pterygoid  plexus  of  veins  and  the  cavern- 
ous sinus  ;  the  nasal  veins  communicate  through  the  foramen  caecum 
with  the  longitudinal  sinus,  and  the  occipital  veins  communicate  with 
the  transverse  sinus  by  the  emissaria  mastoidea.^  Hence,  bleeding  at 
the  nose,  puffiness  of  the  eyelids,  swelling  of  the  facial  vein,  and  of 
the  occipital  veins,  accompany  thrombosis  of  the  sinuses.  From  the 
same  cause  there  will  be  prominence  of  the  eyeballs,  injection  of  the 
conjunctivae,  and  a  swollen  and  tortuous  condition  of  the  retinal  veins, 
cloudy  swelling  of  the  optic  disk  (choked  disks),  etc.  In  the  case  of 
thrombus  of  the  cavernous  sinus,  there  may  be  irritation  by  pressure 
of  the  fifth  nerve,  and  consequent  neuralgia — of  the  fourth,  and  inter- 
nal strabismus  ;  of  the  oculo-motor,  and  contracted  pupil  and  external 
strabismus,  etc.  These  symptoms  have  a  high  degree  of  importance  if 
present ;  but  their  absence  does  not  negative  the  existence  of  throm- 
bosis. During  the  course  of  chronic  otorrhoea  and  caries  of  the  petrous 
bone,  cerebral  symptoms  may  supervene,  and  a  fever  of  septicsemic 
character  develop.  When  delirium  tending  to  coma  accompanied  with 
typhoid  symptoms  appears  during  erysipelas  or  phlegmon  of  the  upper 
lip,  there  may  be  suspected,  as  in  the  former  case,  that  the  new  symp- 
toms maybe  due  to  thrombosis  of  a  sinus.  The  diagnosis  must  always 
be  largely  conjectural. 

*  Henle,  "  Gefasslehrc,"  p.  341. 


504  DISEASES   OF  THE   NERVOUS  SYSTEM. 

Treatment. — The  treatment  consists  in  the  free  use  of  carbonate  of 
ammonia  and  quinia,  given  with  the  objects  in  view  indicated  under  the 
head  of  occlusion  of  the  cerebral  vessels.  Unfortunately,  when  this 
accident  occurs,  there  is  little  chance  of  accomplishing  any  good. 
Whenever  a  phlegmon  of  the  upper  lip  appears,  the  probability  of  this 
accident  should  be  kept  in  view.  Free  administration  of  quinia  is  un- 
doubtedly serviceable  in  preventing  this  complication. 

CEREBRAL  H.S3MORRHAGE. 

Definition. — By  this  term  is  meant,  the  giving  way  of  a  vessel  and 
the  escape  of  blood  into  the  cerebral  tissues.  Apoplexy  is  sometimes 
used  synonymously  with  cerebral  hemorrhage,  but  incorrectly,  since  it 
is  a  symptom  merely,  and  not  a  disease. 

Causes. — The  principal  cause  of  cerebral  hemorrhage  is  disease  of 
the  vessels — aneurismal  dilatations  seated  on  the  arterioles  and  vary- 
ing in  size  from  a  pin's-head  to  bodies  too  minute  for  the  unaided  sight 
to  recognize.  It  is  rare  for  these  bodies  to  form  before  forty,  but  they 
occur  with  increasing  frequency  with  the  advance  in  life.  The  change 
is  a  periarteritis  and  begins  in  the  perivascular  lymph-sheaths,  thence 
extends  to  the  adventitia,  the  muscular  layer  dilates,  and  the  aneurism 
is  formed.*  Atheromatous  degeneration  of  the  tunics  of  the  vessels 
may  be  an  indirect  cause,  by  leading  to  the  formation  of  the  miliary 
aneurism.  Increase  in  the  blood-pressure  is  said  to  have  an  influence 
in  causing  haemorrhage,  but  not  directly.  When  disease  has  weakened 
the  vessels,  an  increase  in  the  blood-pressure  will  caxxse  them  to  yield, 
but,  without  such  change  in  the  walls  of  the  vessels,  mere  variations 
of  pressure  will  not  suffice.  The  principal  source  of  increased  blood- 
pressure  is  hypertrophy  of  the  left  ventricle — that  form  associated 
w^ith  hypertrophy  of  the  muscular  layer  of  the  arterioles  and  contract- 
ed or  fibroid  kidney.  Besides  the  constantly  exalted  pressure,  the 
intra-cranial  vessels  may  be  exposed  to  sudden  increased  strain  by  a 
variety  of  causes  :  by  stimulants,  as  alcohol,  opium,  coffee,  tea,  etc.  ; 
by  a  cold  or  hot  bath,  by  a  full  meal,  and  by  moral  emotion.  Cerebral 
haemorrhage  is  notably  increased  by  the  cold  weather  of  autumn.  Ve- 
nous hyperaemia  may  lead  to  cerebral  haemorrhage,  as  coughing,  strain- 
ing at  stool,  coitus,  etc.,  but  disease  of  the  vessel-walls  must  pre- 
dispose to  the  accident.  The  arterial  disease  on  which  haemorrhage 
depends  is  probably  transmissible,  for  it  is  a  matter  of  common  ob- 
servation that  the  tendency  to  cerebral  haemorrhage  is  inherited. 

Pathological  Anatomy.  —  Certain  parts  of  the  brain  seem  particu- 
larly liable  to  cerebral  hemorrhage  :  the  corpus  striatum,  the  lenticular 
nucleus,  the  thalamus  opticus.  When  these  parts  are  affected,  the  dam- 
age is  not  always  confined  to  them,  but  the  neighboring  parts  of  the 
*Eichler,  "Deutsch.  Archiv  fiir  klinische  Med.,"  xxi,  1,  32. 


CEREBRAL   HEMORRHAGE.  505 

hemisphere  are  damaged  simultaneously,  and  the  lobes  of  the  hemi- 
spheres are  often  separately  attacked,  the  anterior  and  middle  more  fre- 
quently than  the  posterior  lobe.  Next  in  point  of  frequency,  but  much 
less  often,  the  cerebellum  is  involved,  and. lastly,  although  rarely,  the 
pons  and  medulla.  The  blood  is  not  necessarily  confined  to  the  point 
whence  it  escaped  :  it  may  break  through  to  the  surface  or  into  the  ven- 
tricles and  pass  by  the  iter  from  the  third  to  the  fourth  ventricle.  When 
the  amount  is  large,  the  dura  mater  may  be  put  on  the  stretch,  the  con- 
volutions compressed,  the  sulci  lessened  in  depth.  The  blood  may  be 
collected  in  a  mass  or  focus,  or  it  may  be  spread  out  into  a  more  or 
less  thin  layer.  When  in  a  focus,  as  is  most  usual,  the  collection  is 
somewhat  circular  and  varies  in  size  from  a  pea  to  an  English  walnut, 
or  larger.  There  may  be  one  or  several  foci,  and  they  may  occur  in 
symmetrical  parts — as  a  focus  in  each  corpus  striatum,  for  example. 
Besides  a  recent  there  may  remain  the  evidences  of  former  haemor- 
rhages. Immediately  after  it  has  occurred  there  is  a  blood-clot,  dark 
in  color  and  homogeneous  in  its  constituents,  which  are  those  of  blood 
merely,  although  around  it  is  broken-down  cerebral  matter,  mixed 
with  blood-clot,  and  in  the  mass  somewhere  will  be  found,  if  carefully 
traced  out  in  water,  the  affected  vessel  and  its  ruptured  miliary  aneu- 
rism. Soon  after  the  clot  has  formed,  separation  begins,  and  the  fibrin 
collects  in  the  center  of  the  mass  or  at  the  periphery,  while  the  cor- 
puscles adhere  in  a  group,  and  the  serum  pressed  out  saturates  the  adja- 
cent broken-up  cerebral  matter.  The  next  step,  if  death  does  not  oc- 
cur, is  the  retrograde  change  in  the  blood-clot,  which  becomes  first  of 
a  dark  chocolate-color,  but  the  h£ematin  disappears,  the  watery  part 
is  absorbed,  and  a  yellow,  puriform-looking  material  only  remains.  A 
limiting  inflammation  may  occur  in  the  adjacent  cerebral  matter,  a  con- 
nective-tissue membrane  of  a  spongy  structure  forms,  and  the  remains 
of  the  clot  will  be  inclosed  in  this.  Besides  the  yellowish,  puriform 
fluid  or  a  whitish,  whey-like  fluid,  there  are  contained  crystals  of  pig- 
ment in  the  meshes  of  the  cyst-walls.  The  clot  and  the  surrounding 
brain-substance  do  not  always  undergo  this  favorable  disposition.  An 
inflammation  may  be  lighted  up  in  the  brain-tissue,  around  the  clot, 
in  a  few  days  after  it  has  formed,  producing  extensive  softening  and 
cedema.  The  cysts  formed  may  continue  indefinitely  without  further 
change,  or  they  may  ultimately  disappear,  leaving  only  a  cicatrix  of 
considerable  area,  but  thin,  and  composed  of  either  dense  connective 
tissue,  or  of  a  spongy  material  containing  pigment.  The  changes  due 
to  cerebral  haemorrhage  are  not  limited  to  the  site  of  the  original  in- 
jury. Some  months  after wai'd  an  atrophic  degeneration  has  taken 
place  in  the  nerve-fibers  of  the  pyramidal  tracts.  These  degenerative 
changes  do  not  follow  all  cases  of  cerebral  haemorrhage.  They  occur 
after  haemorrhage  into  the  internal  capsule,  the  corpus  striatum,  the 
gray  matter  of  the  motor  zone,  and  the  subjacent  white  substance,  and 


506  DISEASES   OF  THE   NERVOUS  SYSTEM. 

less  SO  when  the  lesion  is  in  the  optic  thalamus  and  centrum  ovale, 
and  not  at  all  when  the  haemorrhage  is  in  the  caudate  nucleus.*  The 
atrophy  extends  downward  through  the  cms,  the  2^ons,  and  the  py- 
ramidal tracts,  and  consists  in  wasting  of  the  nerve-elements  and  an 
increase  of  the  connective  tissue. 

Symptoms. — Many  cases  of  cerebral  hsemorrhage  are  preceded  by 
distinct  prodromes.  The  most  usual  are  those  connected  with  chronic 
arteritis,  which  may  lead  to  thrombosis,  or  less  frequently  those  de- 
pendent on  cerebral  hyperaemia.  Headache,  vertigo,  sudden  attacks 
in  which  the  mind  is  confused,  the  memory  for  words  is  lost,  or  mis- 
takes in  the  use  of  words  occur  ;  changes  in  the  disposition,  becoming 
morose,  dejected,  and  irritable,  weakness  of  a  limb  or  of  one  side, 
numbness,  tingling,  or  a  feeling  of  coldness  in  a  member  or  several 
members,  double  vision,  weakness  of  the  tongue,  paresis  of  the  facial 
muscles,  etc.  Sometimes,  as  the  author  has  witnessed,  the  apoplecti- 
form variety  of  cerebral  congestion  is  followed  in  a  few  weeks  by 
severe  or  fatal  cerebral  haemorrhage.  In  many  cases  there  are  no 
"warnings,"  no  prodromata,  but  the  haemorrhage  occurs  suddenly. 
The  character  of  the  seizure  varies  greatly.  It  may  be  apoplectic  ;  the 
patient  utters  a  cry  or  a  groan,  and  falls  insensible.  Usually  some 
svmptoms  occur  just  previously  to  the  loss  of  consciousness  ;  there  is 
headache  of  a  very  intense  kind,  or  giddiness  with  nausea  and  vomit- 
ing, or  the  tongue  is  paralyzed  and  speech  impossible,  or  there  is  de- 
lirium or  incoherent  rambling,  or  there  is  gaping,  a  feeling  of  great 
desire  for  sleep,  and  increasing  drowsiness,  or  there  may  be  intense 
weakness  of  the  limbs  and  a  feeling  of  exhaustion,  or  one  limb  may  be 
seized  with  intense  numbness  and  tingling,  or  there  may  be  spasm 
of  the  muscles  soon  to  be  paralyzed — in  a  great  variety  of  ways  the 
attack  may  be  announced  some  hours  or  minutes  before  the  blow  falls. 
The  i^atient  passes  into  unconsciousness,  with  complete  muscular  re- 
laxation, and  the  extinction  of  reflex  movements,  the  action  of  the 
heart  and  the  respiration  continuing.  In  the  less  severe  cases  the 
unconsciousness  is  profound,  but  strong  irritation  may  induce  reflex 
movements,  and  swallowing  is  possible  if  the  substance  is  placed  in 
the  pharynx,  and  a  difference  between  the  movements  of  the  two  sides 
is  also  apparent.  The  eyes — and  the  head,  also,  frequently — deviate 
toward  the  side  affected  in  the  brain  and  from  the  side  paralyzed  : 
this  movement  constitutes  a  means  of  diagnosis  between  cerebral  haem- 
orrhage and  other  causes  of  profound  unconsciousness.  Convulsions 
of  the  epileptiform  variety  may  occur,  when  the  haemorrhage  causes 
unconsciousness,  and  usually  signifies  large  hsemorrhage,  or  haemor- 
rhage into  the  pons  or  medulla.  When  the  haemorrhage  occurs  slowly, 
and  the  patient  glides  gradually  into  unconsciousness,  there  may  be 

*  Flechsitr,  "  Archiv  fiir  Heilkunde,"  ISYY,  and  No.  53,  1878. 


CEREBRAL   HEMORRHAGE.  507 

nausea,  vomiting,  and  pallor  of  the  face,  but  in  most  cases  of  cerebral 
haemorrhage  the  face  is  rather  red  and  flushed.  There  is  no  constant 
rule  as  to  the  size  of  the  pupils  :  a  very  minutely  contracted  pupil 
usually  signifies  hjemorrhage  into  the  pons  ;  and  unequal  pupils,  one 
being  largely  dilated,  indicate  a  large  hosmorrhage  breaking  through 
into  the  lateral  ventricle.  The  breathing  has  usually,  but  by  no  means 
invariably,  the  stertorous  character,  by  which  is  meant  the  drawing 
in  of  the  paralyzed  cheek  with  inspii'ation  and  its  puffing  out  with  a 
sort  of  explosion  in  expiration.  The  pulse  is  small  or  full,  slow  or 
irregular,  usually  slow  and  full.  There  are  apoplectic  examples  of 
cerebral  haemorrhage  in  which  the  unconsciousness  is  not  profound — 
the  patient  may  be  roused,  if  he  is  loudly  called,  but  lapses  into  a 
soporose  state  at  once.  There  are  many  cases  in  which  conscious- 
ness is  not  lost  at  all :  there  may  be  a  temporary  confusion,  or  some  of 
the  symptoms  called  prodromal,  and  then  paralysis  of  one  side  occurs. 
Often  it  is  sudden  and  complete  ;  again  it  comes  on  slowly,  and  is  not 
complete  for  some  minutes.  In  the  apoplectic  form,  death  may  occur 
during  the  unconsciousness — in  from  five  minvites  to  three  days.  The 
fulminant  cases,  which  terminate  in  a  few  minutes,  are  comparatively 
rare — sudden  death  being  usually  caused  by  heart-disease.  If  uncon- 
sciousness continues  longer  than  twenty-four  hours,  death  is  the  usual 
result.  The  temperature  during  the  period  of  unconsciousness  is  low 
— ^below  the  normal,  one  or  two  degrees — ^but  at  the  end  of  the  first 
day  a  rise  to  normal  or  a  little  above  takes  place,  and,  if  a  fatal  result, 
there  is  a  great  rise  just  before  death.  Pneumonia  is  apt  to  be  the 
cause  of  death,  especially  when  the  cerebral  lesion  is  somewhere  in  the 
right  hemisphere,  as  Brown-Sequard  has  demonstrated.  Consciousness 
may  return  in  a  few  minutes,  but  usually  in  from  half  an  hour  to  three 
hours.  Again,  the  effects  of  the  seizure  may  continue  for  days,  there 
being  stupor,  confusion  of  mind,  defects  of  speech.  The  return  of 
consciousness  is  indicated  by  the  revival  of  reflex  excitability,  by  the 
effects  of  irritation,  etc.  The  progress  of  restoration  may  be  retarded 
by  the  onset  of  inflammatory  symptoms  at  the  expiration  of  two  or 
three  days  ;  the  temperature  rises  a  degree  or  two  ;  headache,  confu- 
sion of  mind,  and  delirium  occur  ;  tonic  contractions  ("  early  rigid- 
ity") ensue  in  the  paralyzed  muscles,  and  they  become  the  seat  of 
severe  pain,  which  may  persist  for  a  month  or  more,  while  the  other 
symptoms  disappear  in  a  few  days. 

When  the  disturbances  due  to  the  seizure  subside,  then  may  be 
clearly  seen  the  extent  of  the  paralysis.  The  shock  of  the  attack  sus- 
pends the  functions  of  many  parts  of  the  cerebrum,  which  soon  func- 
tionate again  as  these  effects  of  the  injury  subside.  Various  paretic 
and  paralytic  symptoms,  that  appear  at  first,  quickly  cease,  but  the 
more  permanent  results  are  the  more  evident.  The  amount  of  paraly- 
sis varies  from  a  hardly  appreciable  weakness  to  an  absolute  extinction 


508  DISEASES   OF   THE   NERVOUS   SYSTEM. 

of  motility.  As  there  is  usually  but  one  focus  of  haemorrhage,  the 
resulting  paralysis  is  unilateral,  and  on  the  side  opposite  the  lesion, 
and  involves  the  muscles  of  the  face,  of  the  tongue,  of  the  body,  and 
of  the  extremities — right  or  left  hemiplegia — according  to  the  cere- 
bral hemisphere  invaded.  The  muscles  of  the  face  paralyzed  are  those 
of  expression,  and  are  innervated  by  the  seventh  nerve.  Those  branches 
of  the  nerve  distributed  to  the  orbicularis  palpebrarum,  corrugator 
supercilii,  and  the  frontalis  are  but  slightly  affected,  the  labio-nasal 
fold  is  flattened  or  obliterated,  and  the  corner  of  the  mouth  is  de- 
pressed. The  tongue  when  protruded  deviates  toward  the  paralyzed 
side,  and  the  palate  may  hang  lower  than  normal  and  turned  toward 
either  side.  In  consequence  of  the  paralysis  of  the  expression  muscles, 
many  movements  become  awkward  or  impossible,  as  whistling,  purs- 
ing up  the  mouth,  laughing,  etc.  The  muscles  of  the  chest  are  paretic, 
and  respiration  somewhat  hindered  thereby  (Nothnagel*).  The  ex- 
tensors seem  to  be  more  affected  than  the  flexors,  but  this  is  only 
apparent,  because  of  the  greater  power  of  the  latter.  Notwithstanding 
the  immense  preponderance  of  cases  proving  the  crossing  of  the  motor 
fibers,  and  consequently  the  occurrence  of  hemiplegia  on  the  side 
opposite  the  seat  of  the  lesions  of  the  brain,  there  are  opposing  obser- 
vations. Bilateral  paralysis  may  be  due  to  simultaneous  lesions  on 
both  sides,  and  in  this  way  bilateral  hemiplegia  may  be  produced. 
Paralyses  are  said  to  be  "  alternating  "  or  "  crossed  "  when  the  paraly- 
sis of  the  face  is  on  one  side  and  of  the  extremities  on  the  other.  This 
may  occur  in  lesions  of  the  pons,  etc.  Although  the  paralyzed  parts 
may  be  motionless,  they  may  execute  "  associated  movements  "  :  thus, 
in  coughing  or  sneezing  the  paralyzed  member  may  give  a  jerk,  or  may 
imitate  movements  performed  by  the  healthy  side.  The  contractions 
which  accompany  the  haemorrhage,  or  which  are  excited  by  an  inflam- 
matory process  about  the  site  of  the  clot  in  a  few  days  after  the  seizure 
(early  rigidity),  have  already  been  referred  to.  The  contraction  which 
occurs  later,  after  the  paralysis  has  existed  for  a  long  time,  is  known 
as  "  late  rigidity,"  but  its  intensity  and  persistence  bear  no  constant 
relation  to  the  character  of  the  case,  except  its  duration,  and  rigidity 
may  not  be  present  at  all,  although  not  often  absent.  Bouchard's  ex- 
planation that  the  rigidity  depends  on  the  atrophic  descending  changes 
in  the  cord  has  been  disproved,  and  a  satisfactory  explanation  remains 
to  be  given.  Besides  rigidity,  long-paralyzed  members  may  be  affected 
by  choreic  movements,  first  described  by  our  Mitchell  and  subsequent- 
ly studied  by  Charcot,  under  the  title  "  post-hemiplegic  chorea,"  and 
now  ascertained  to  be  produced  by  changes  in  the  motor  centers  on  the 
opposite  side.  We  have  further  to  note  that  the  paralyzed  muscles 
preserve  their  electric  excitability.     Under   some  circumstances  the 

*  Ziemssen's  "  Clycopa3dia,"  op.  cit. 


CEREBRAL   HJ]:MORRHAGE.  509 

electric  excitability  may  be  heightened,  under  others  lessened,  but  this 
lowering  of  electro-contractility  becomes  more  decided  the  more  nearly 
the  paralysis  approaches  the  "  spinal "  character,  which  is  the  case  in 
lesions  of  the  cerebral  peduncles,  of  the  pons,  and  of  the  medulla. 
Immediately  on  the  receipt  of  the  injury  done  by  the  haemorrhage,  the 
sensibility  is  paralyzed  with  the  motion,  but  the  sensibility  is  soon 
restored,  as  a  rule,  although  sometimes  the  restoration  is  very  gradual, 
and  it  is  rai-e  for  it  to  be  complete.  Anaesthesia  and  analgesia  do  not 
accompany  lesions  of  the  corpus  striatum,  whence  it  happens  that  these 
functions  are  so  seldom  permanently  impaired  in  hemiplegia.  In 
some  cases — lesions  of  the  thalamus,  corona  radiata,  etc. — anaesthesia 
may  be  a  constant  symptom.  Anaesthesia  may  be  followed  by  hyper- 
algesia, and  the  paralyzed  members  may  be  the  seat  of  neuralgia. 
Various  trophic  changes  occur  in  hemiplegia.  With  the  first  hemi- 
plegia, the  paralyzed  parts  are  usually  somewhat  swollen,  are  red,  and 
possess  a  slightly  higher  temperature,  and  sweat  a  good  deal.  These 
symj^toms  subside  in  a  few  weeks  or  two  or  three  months  ;  the  affect- 
ed parts  become  cold,  pale  or  bluish,  the  skin  scaly  and  dry,  and  the 
nails  grow  wrinkled,  thickened,  brittle,  and  incurved,  and  the  hair 
changes  in  texture  and  length.  The  skin  grows  thicker  and  tougher 
in  many  cases,  and  the  larger  joints  may  be  the  seat  of  an  acute  syno- 
vitis. In  addition  to  these  trophic  affections  should  be  mentioned 
the  fact  that  the  paralyzed  members  in  hemiplegia  rapidly  ulcerate 
by  pressure  (bed-sores). 

Course,  Duration,  and  Termination. — In  the  fulminant  form  death 
may  occur  in  a  few  minutes,  never  less  than  fifteen.  There  may  be 
a  partial  revival,  the  consciousness  restored  more  or  less  completely, 
and  then  a  new  attack  occurs,  closing  the  scene  usually  in  a  day  or  two. 
The  apoplectic  symptoms  having  disappeared,  the  next  danger  consists 
in  the  inflammation  about  the  clot,  the  febrile  excitement,  headache,  and 
delirium,  which  usually  prove  fatal  within  a  week,  unless  very  mild  and 
transitory.  Having  passed  this  period  there  is  a  partial  recovery  with 
hemiplegia,  which  may  gradually  disappear,  leaving  but  slight  traces 
of  the  original  mischief.  There  are  but  few  if  any  w^ho  are  restored 
entirely  in  all  their  mental  powers,  although  the  motor  paralysis  may 
have  ceased.  If  changed  in  no  other  way,  they  are  emotional,  easily 
excited  to  tears,  or  become  altered  in  disposition,  appearing  irritable, 
excitable,  peevish.  Usually  memory  is  impaired,  especially  for  the 
events  of  the  time,  while  matters  long  past  of  early  life  may  be  vividly 
recalled.  The  memory  for  words  may  be  impaired  slightly,  may  be 
very  defective,  or  may  be  entirely  lost,  constituting  the  condition  of 
aphasia.  This  may  include  inability  to  express  ideas  by  signs.  There 
may  be  a  gradual  decline  in  the  mental  powers,  the  patient  lapsing 
into  dementia.  The  duration  of  a  case  of  hemiplegia  is  very  uncertain 
— many  continue  for  ten,  fifteen,  even  twenty  years.     But  hemiplegics 


^10  DISEASES   OF  THE  NERVOUS   SYSTEM. 

are  always  tlireatened  by  a  new  attack,  since  the  lesions  which  origi- 
nally caused  it  are  yet  present.  Another  attack  or  two  is  the  usual 
course,  proving  fatal  ultimately  unless  cut  off  by  an  intercurrent  dis- 
ease. 

Diagnosis. — As  the  subject  of  the  distinction  between  occlusion  of 
the  cerebral  vessels  and  cerebral  hsemorrhage  has  been  discussed,  it 
remains  now  to  indicate  the  seat  of  the  lesions  by  the  symptoms.  The 
diagnosis  of  the  position  of  the  haemorrhage  by  the  symptoms  rests  on 
the  knowledge  of  cerebral  localizations.  Lesions  of  the  cortex  and  of 
the  medullary  substance  of  the  hemispheres  may  give  rise  to  paralysis 
on  the  opposite  side  of  the  body.  If  slight  in  extent,  recovery  may 
ensue.  A  lesion  confined  to  the  third  left  frontal  convolution  has  pro- 
duced aphasia  only.  Disturbances  in  the  mental  functions  are  usual 
and  are  more  decided  than  the  psychical  symptoms  produced  by  cere- 
bral haemorrhage  into  other  parts.  Haemorrhage  into  the  anterior  lobe 
causes  paralysis  of  the  opposite  half  of  the  body,  and  aphasia  if  the 
left  is  the  seat  of  the  lesion.  Haemorrhage  into  any  of  the  parts  sup- 
plied by  the  left  middle  cerebral  will  produce  disturbance  in  all  the 
modes  of  expressing  ideas  by  words  and  signs.  Sensibility  as  well  as 
motility  is  disordered  in  haemorrhage  into  the  posterior  middle  lobe 
and  into  the  posterior  lobe.  Disturbances  of  vision  and  optic  neuritis 
accompany  the  paralysis,  and  psychical  disorders,  with  a  special  ten- 
dency to  emotional  manifestions,  are  pronounced  features.  Haemor- 
rhage breaking  into  the  ventricles  is  accompanied  by  formidable  symp- 
toms ;  by  deep  coma,  sometimes  by  convulsions,  partial  or  general, 
occasionally  by  contractions  of  the  paralyzed  parts,  by  unequal  pupils, 
one  being  widely  dilated.  Haemorrhage  into  the  corpus  striatum, 
the  most  usual  site  of  cerebral  haemorrhage,  is  followed  by  paralysis 
of  the  members,  body,  and  face  on  the  opposite  side  ;  and,  if  in  the 
left  corpus  striatum,  affections  of  speech,  sometimes  complete  apha- 
sia, are  usually  present.  There  are  no  disturbances  of  sensibility  in 
these  cases  of  hemiplegia  from  haemorrhage  into  the  corpus  striatum. 
As  the  optic  thalami  have  never  been  invaded  by  haemorrhage  strictly 
limited  to  them,  the  results  of  lesions  are  hemiplegia  of  the  opposite 
side  and  affections  of  sensibility.  It  is  probable  that  the  motor  symp- 
toms are  due  to  simultaneous  injury  to  the  corpus  striatum.  Haemor- 
rhage into  the  pons  or  medulla  is  very  fatal — in  from  fifteen  minutes 
to  several  hours.  There  are  convulsions  usually,  general  muscular  res- 
olution, and  minutely  contracted  pupils.  If  the  immediate  results  are 
passed  over,  various  motor  disturbances  ensue  :  there  may  be  paralysis 
of  both  sides,  or  paraplegia,  paralysis  of  one  side,  or  hemiplegia  ;  pa- 
ralysis of  the  members  on  one  side  and  of  the  face  on  the  opposite 
side,  or  crossed  paralysis  ;  also  sensory  disturbances  :  there  may  be 
anaesthesia  with  the  paralysis  of  one  side,  and  the  paralysis  of  sensa- 
tion may  be  "  crossed,"  as  is  the  motor  paralysis. 


CEREBRAL   HAEMORRHAGE.  511 

Treatment. — If  the  prodromal  symptoms  threaten  an  attack  of 
cerebral  haemorrhage,  venesection,  as  the  most  prompt  and  efficient 
means  for  reducing  the  intra-cranial  blood-pressure,  should  be  at  once 
practiced,  the  amount  drawn  being  decided  by  the  effect  produced. 
In  feeble  subjects,  leeches  to  the  mastoid  may  be  substituted  for  vene- 
section. An  active  purgative  (compound  extract  of  colocynth  gr.  vj, 
croton-oil  gt.  j)  should  be  administered.  Counter-irritants  should  be 
applied  to  the  extremities,  and  an  ice-bag  to  the  scalp.  If  the  haem- 
orrhage have  occurred,  these  measures  will  be  useless.  The  utmost 
quiet  should  then  be  maintained,  the  head  elevated,  the  room  dark- 
ened. Excellent  results  are  then  obtained  by  the  use  of  tincture  of 
aconite-root,  beginning  immediately  after  the  coma  has  passed  off. 
One  drop  every  two  hours  will  usually  suffice,  as  it  is  not  necessary 
to  reduce  the  pulse  by  it,  unless  the  reactive  fever  is  considerable, 
when  the  dose  mentioned  may  be  given  every  hour  for  a  day  or  two. 
When  the  reaction  period  has  passed,  or  at  the  end  of  two  weeks, 
much  may  be  accomplished  by  the  judicious  use  of  ammonia  (ammon. 
carb.  gr.  v,  liq.  ammonii  acetat.  3  ss.,  four  times  a  day),  continuing  it 
for  a  month  or  more,  or  until  the  retrograde  changes  in  the  blood- 
clot  are  accomplished.  Then  the  time  has  arrived  for  the  application 
of  galvanism,  a  weak  current — say  from  four  cups — being  passed 
through  the  brain  in  both  directions,  or  from  behind  forward,  and 
from  both  mastoids.  The  application  should  be  daily,  and  for  three 
minutes  at  a  seance.  To  assist  in  the  restoration,  the  lactophosphate 
of  lime  (sirup)  should  be  administered  three  times  a  day  with  the 
meals,  and  the  diet  should  be  nourishing  and  yet  unstimulating.  As 
the  tendency  of  paralyzed  parts  is  to  waste,  the  members  should  from 
the  beginning  be  subjected  to  daily  massage,  at  first  very  lightly,  and, 
if  wasting  of  the  muscles  is  considerable,  they  should  be  exercised  by 
faradization.  If  there  is  much  contraction  of  the  flexors,  the  extensors 
should  be  faradized,  and  the  flexors  should  receive  a  continuous  mild 
current  to  allay  their  irritability.  When  there  is  no  longer  any  local 
irritation  about  the  site  of  the  haemorrhage,  the  injections  of  strychnia 
should  be  practiced  into  the  affected  muscles.  During  the  long  period 
after  the  absorption  of  the  clot,  when  the  paralysis  remains  stationary 
or  slowly  improves,  good  results  are  obtained  from  the  persistent  use 
of  lactophosphate  of  lime  and  cod-liver  oil,  which  act  as  nutrients  to 
the  cerebral  matter.  These  may  be  given  when  electricity  and  the 
injections  of  strychnia  are  practiced. 

CEREBRAL  HEMORRHAGE— MENINGEAL. 

PatllOgeny. — Haemorrhage  into  the  meninges  may  be  caused  by 
injury  ;  as,  for  example,  the  meningeal  artery  may  be  ruptured  by  a 
fracture,  involving  the  anterior  inferior  angle  of  the  parietal  bone. 


512  DISEASES   OF   THE   NERVOUS   SYSTEM. 

The  most  usual  cause,  probably,  is  aneurism,  and  the  vessel  most 
frequently  the  seat  of  this  disease  the  basilar,  except  the  meningeal 
hsemorrhage  of  newly-born  children,  which  is  really  traumatic,  and 
produced  by  forceps  delivery.  Meningeal  hsemorrhage  is  a  complica- 
tion of  the  acute  infectious  diseases.  The  blood  is  found  in  a  thin 
layer,  under  the  dura  or  in  the  cavity  of  the  arachnoid,  at  the  base  on 
the  hemispheres,  and  in  both  situations  at  the  same  time.  The  brain 
itself  may  be  injured  by  the  escape  of  blood  from  an  aneurism,  and 
the  convolutions  may  be  depressed,  the  brain-substance  pale  and  ex- 
sanguine. 

Symptoms. — As  meningeal  hsemorrhage  occurs  in  the  adult,  the 
phenomena  attendant  on  it  are  the  same  as  those  of  a  large  cerebral 
hsemorrhage.  There  are  coma,  complete  muscular  resolution,  often 
succeeding  to  convulsions  of  an  epileptiform  character,  pupils  unequal, 
and  reflex  movements  entirely  suspended.  Death  may  occur  in  a  few 
minutes,  or  after  several  hours,  in  profound  coma.  In  other  cases 
there  are  headache,  dizziness,  nausea,  and  vomiting,  drowsiness,  pass- 
ing into  stupor,  then  coma  until  death  after  some  hours — symptoms 
supposed  to  be  due  to  the  gradual  escape  of  blood  from  a  ruptured 
vessel.  In  new-born  children  meningeal  hsemorrhage  is  a  common 
cause  of  asphyxia,  from  which  they  can  not  be  roused. 


INFLAMMATION  OF  THE  DURA  MATER— PACHYMENINGITIS 
EXTERNA  AND  INTERNA— H.ffiMATOMA  OF  THE  DURA 
MATER. 

Definition. — ^j  pachymeningitis  is  meant  an  inflammation  of  the 
dura  mater.  As  this  membrane  consists  of  two  layers,  there  are  two 
forms  of  the  inflammation  attacking  it  :  pachymeningitis,  externa  and 
interna.  Pachymeningitis  externa  is  a  surgical  malady — an  inflamma- 
tion of  the  external  lamella  of  the  dura,  excited  by  fractures,  penetrat- 
ing wounds,  and  other  injuries  of  the  skull,  and  by  caries  of  the  pe- 
trous portion,  involving  the  dura  by  contiguity  of  tissue.  The  last- 
mentioned  malady  is  so  intimately  associated  with  abscess  of  the  brain 
that  it  is  more  appropriately  studied  in  connection  with  that  disease. 

Causes. — Pachymeningitis  Interna — Hoematoma  of  the  Dura. — 
Age  is  an  important  factor,  the  tendency  to  this  disease  increasing  from 
twenty  upward,  the  largest  number  per  centum  occurring  from  sev- 
enty to  eighty  (Huguenin).  Three  fourths  of  the  cases  happen  in  men, 
doubtless  because  they  are  more  exposed  to  the  influences  producing 
this  disease.  Trauma  plays  an  important  part,  with  or  without  frac- 
ture of  the  skull.  In  one  of  the  author's  cases  the  hsematoma  fol- 
lowed a  blow  on  the  head — a  contusion — with  the  handle  of  a  heavy 
riding-whip.  No  doubt  the  blow  which  caused  the  mischief  often  is 
forgotten,  and  some  other  cause  assigned.     A  predisposition  may  be 


PACHYMENINGITIS.  513 

created  by  several  morbid  states  :  by  chronic  alcoholism,  scurvy,  per- 
nicious anasmia,  Bright's  disease,  sclerosis  of  the  liver,  diseases  of  the 
heart,  and  obstructive  maladies  of  the  lungs.  Atrophy  of  the  brain, 
caused  by  various  intra-cranial  lesions,  seems  to  be  a  very  important 
factor  in  the  development  of  hsematoma  (Huguenin),  and  to  this  may 
be  added,  by  way  of  illustration,  the  atrophy  of  advanced  age  and  of 
chronic  alcoholismus.* 

Pathological  Anatomy. — The  most  commonly  accepted  view  is  that 
of  Virchow.  The  first  step  in  the  morbid  process  consists  in  a  hyper- 
aemia  of  the  membrane,  and  an  exudation,  developing  into  a  membran- 
ous new  formation,  proceeds  from  the  sub-epithelial  layer  of  the  dura.f 
This  neo-membrane  contains  a  multitude  of  vessels  of  considerable 
size,  and  having  very  thin  walls.  Haemorrhages,  often  of  considerable 
quantity,  take  place  by  the  rupture  of  these  vessels,  and  the  size  and 
thickness  of  the  neo-membrane  are  correspondingly  increased.  Ulti- 
mately the  new  formation  assumes  the  appearance  of  a  cyst,  having  a 
smooth  surface  exteriorly,  and  containing-  within  a  cavity  lined  with 
blood-clot,  shaggy  masses  of  fibrin,  partly  decolorized,  hanging  from 
the  walls,  and  a  fluid  reddish  in  color  and  thick  with  particles  oi  broken- 
up  clot.  At  a  later  period  there  may  be  no  appearances  of  blood-clot, 
except,  it  is  probable,  some  blood-crystals — there  may  be  only  a  cyst, 
filled  more  or  less  full  with  a  pellucid  serum,  or  instead  of  a  cyst 
with  a  single  cavity  there  is  a  mass  of  connective  tissue,  its  fibers  loosely 
united,  spongy,  with  serum  more  or  less  fully  distending  the  inter- 
spaces. Before  its  nature  was  understood  the  cyst  containing  clear 
serum  was  called  "  cyst  of  the  arachnoid."  It  should  be  understood 
that,  between  a  sac  filled  with  blood-clot  and  one  containing  serum 
only,  there  are  various  intermediate  grades,  the  blood  being  more  or 
less  advanced  in  the  process  of  disintegration,  by  which  all  the  raor- 
photic  elements  are  dissolved  and  decolorized.  Huguenin  J  holds  that 
the  formation  of  a  hsematoma  is  not  initiated  by  an  inflammation  of 
the  inner  lamella  of  the  dura,  but  that  the  process  consists  merely  in 
the  orjranization  of  a  hsemorrhagic  extravasation.  An  immediate  vas- 
cular  communication  is  established  between  the  dura  and  the  new  mem- 
brane. The  usual  position  of  the  new  formation  is  on  the  upper  sur- 
face of  the  hemispheres,  extending  downward  toward  the  occipital  lobe, 
corresponding  to  the  parietal  bone,  and  in  more  than  half  the  cases  on 
both  sides.  The  changes  in  the  adjacent  portion  of  the  brain  are  de- 
pendent on  the  size  and  thickness  of  the  neo-membrane.  In  a  case 
observed  by  the  author  the  cyst  was  a  half -inch  in  thickness  at  its 
thickest  part,  and  it  depressed  the  hemisphere  correspondingly,  the 
convolutions  being  flattened,  the  sulci  almost  obliterated,  and  the  ven- 

*  Dr.  Jacob  Kremiansky,  "  Ueber  die  PacTiymeningitis  interna  Iisemorrhagica  bei 
Menschen  und  Hunden,"  Virchow's  "  Arcluv,"  Band  xlii,  S.  129-321. 

f  Rindfleisch,  op.  cit.,  p.  620.  X  Ziemssen's  "  Cyelopsedia,"  vol.  xii. 

33 


514  DISEASES   OF   THE   NERVOUS   SYSTEM. 

tricle  lessened  one  half  of  its  area.  Atrophy  of  the  brain,  atheroma- 
tous degeneration  of  the  vessels,  and  the  alterations  in  the  structure 
of  the  brain,  accompanying  dementia  paralytica,  are  often  present. 
Obstructive  diseases  of  the  lungs  and  valvular  affections  of  the  heart 
are  frequently  associated  with  and  apparently  have  a  causative  rela- 
tion to  this  malady. 

Symptoms. — There  is  necessarily  much  obscurity  about  this  disease, 
and  the  symptoms  are  diffused,  and  but  little  characteristic.  There 
occur  first  the  indications  of  excitement  of  function,  followed  by  those 
of  depression.  In  the  first  group  are  an  obstinate  headache,  vertigo, 
singing  in  the  ears,  contraction  of  the  pupils  to  a  marked  extent,  un- 
certainty and  feebleness  in  the  movements,  without  paralysis,  wakeful- 
ness, and  when  sleep  comes  it  is  disturbed  by  exciting  dreams.  In 
some  cases,  but  less  frequently,  there  occurs  an  attack,  apoplectic  in 
character  and  with  the  usual  phenomena  of  that  state.  The  period  of 
excitation  continues  from  a  few  days  to  three  months,  and  is  succeeded 
by  the  signs  of  cerebral  depression.  At  this  point  in  these  cases  there 
will  usually  occur  attacks  like  those  of  cerebral  haemorrhage  and  from 
the  same  cause,  but  in  this  stage  of  this  disease  they  are  apt  to  pass 
slowly  into  unconsciousness. .  Death  may  occur  in  this  coma,  or  the 
patient  emerges  from  it  slowly,  when  there  will  appear  the  symptoms 
due  to  the  hgematoma  now  produced.  It  should  be  remembered  that 
this  new  formation  is  on  the  surface  of  the  hemisphere,  that  there  has 
been  no  destruction  of  the  cerebral  tissue  as  in  cerebral  haemorrhage, 
and  that  compression  is  exerted  by  it  on  the  brain-mass  on  one  or  both 
hemispheres.  The  symptoms  now  present  are  persistent  headache, 
contracted  pupils,  and  paroxysmal  attacks  of  'somnolence,  persisting  for 
days  at  a  time.  If  the  pressure  is  on  one  side  only,  the  corresponding 
pupil  is  smaller.  Paresis  of  the  muscles,  contractions,  twitching  of  the 
muscles,  are  observed  on  one  side  when  the  lesion  is  unilateral,  or  they 
may  be  double.  Convulsive  movements,  limited  to  a  hand,  or  arm,  or 
leg,  may  be  obseiwed.  Hemiplegia  may  slowly  develop  out  of  a  uni- 
lateral paralysis.  After  existing  on  one  side  for.  a  time,  these  motor 
disturbances  may  slowly  affect  the  other  side,  doubtless  because  of  an 
extension  of  the  disease.  In  one  third  of  the  cases  there  are  defects  or 
embarrassment  of  speech,  but  rarely  complete  aphasia.  There  are  not 
any  disorders  of  sensation.  The  pulse  is  usually  weak,  rapid,  and 
rather  irregular.  Fever  has  been  noted  in  many  cases.  The  pulse  may 
be  slow  during  the  haemorrhage. 

Course,  Duration,  and  Termination. — The  first  stage,  or  that  of  ex- 
citation, usually  lasts  but  a  day  or  two,  yet  in  exceptional  cases  it  may 
continue  a  month  or  two.  Death  may  occur  in  the  apoplexy.  The 
period  of  depression  lasts  usually  from  a  week  to  one  month,  and  may 
continue  a  year,  but  the  most  common  duration  is  about  twenty  days. 
Although  death  is  the  usual  result,  recovery  may  take  place,  but  it  is 


ACUTE   HYDROCEPHALUS.  515 

doubtful   whether   the    mental   faculties   are  ever  again  entirely  re- 
stored. 

Treatment. — The  remedial  management  of  this  disease  is  a  discour- 
aging undertaking.  The  usual  remedies  for  cerebral  hypersemia  may 
be  used  for  the  symptoms  of  excitation. 


ACUTE   HYDROCEPHALUS. 

Definition. — The  term  hydrocephalus  signifies  water  in  the  brain, 
but  is  restricted  to  a  disease  characterized  by  the  presence  of  a  serous 
fluid  in  the  arachnoid  spaces,  in  the  pia  mater,  in  the  brain-substance 
(oedema),  and  in  the  ventricles.  Hydrocephalus  may  be  congenital  or 
acquired.  The  latter  variety  is  the  form  under  discussion.  Although 
a  term  which  expresses  a  symptom  merely,  hydrocephalus  does  not  in- 
volve a  theory,  but,  like  hydrothorax,  serves  to  distinguish  an  effusion 
which  arises  from  causes  non-inflammatory. 

Causes. — Mechanical  causes,  which  prevent  the  return  of  blood  from 
the  vena  Galeni  and  the  right  sinus,  will  induce  effusion  into  the  ven- 
tricle. Intra-cranial  tumors,  bands  of  false  membrane,  obstruction  of 
a  sinus  or  tumors  of  the  neck  so  situated  as  to  compress  the  jugular 
vein,  belong  to  this  category.  Disease  of  the  right  heart,  obstructive 
diseases  of  the  lungs,  as  emphysema,  sclerosis,  etc.,  may  cause  hydro- 
cephalus by  mechanical  interference  with  the  circulation.  In  advanced 
age,  ventricular  dropsy  occurs  in  consequence  of  atrophy  and  shrinking 
of  the  brain.  Various  cachexise  affect  the  intra-cranial  circulation  and 
cause  dropsy,  as  Bright's  disease,  cancer,  tuberculosis,  etc.,  but  only 
the  first  named  stands  in  a  causative  relation  to  the  form  of  hydro- 
cephalus here  considered.  Dropsy  of  the  ventricles  coincides  with 
general  dropsy  from  cardiac  and  renal  diseases.  Hydrocephalus  is  more 
especially  a  disease  of  early  life,  from  one  to  five  years  of  age,  but  it 
may  occur  at  any  age.  Unfavorable  hygienic  conditions  increase  the 
tendency  to  it,  and  the  predominance  of  the  nervous  system  in  the  bod- 
ily conformation  invites  this,  as  other  forms  of  nervous  disease.  Both 
sexes  are  affected  alike.  Among  the  exciting  causes  may  be  men- 
tioned dentition,  the  eruptive  fevers,  and  blows  on  the  head. 

Pathological  Anatomy.— The  effusion  is  usually  confined  to  the 
ventricles,  but  there  may  be  considerable  distention  of  the  subarach- 
noid spaces,  oedema  of  the  pia  and  of  the  neighboring  portions  of  the 
brain.  When  the  effusion  is  limited  to  the  ventricles,  the  brain-tissue 
is  found  to  be  moister  from  the  gray  matter  inward.  More  or  less 
softening  by  imbibition  exists  for  a  short  distance  from  the  ventricles. 
The  choroid  plexus  is  hyperaemic,  and  may  contain  minute  extravasa- 
tions. The  ventricles  are  usually  symmetrically  dilated,  but,  in  the 
hydrocephalus  of  the  aged,  one  ventricle  may  be  very  much  dilated 
and  the  other  encroached  on  and  narrowed. 


516  DISEASES   OF   THE   XERVOUS   SYSTEil. 

Symptoms. — -There  are  several  modes  of  onset,  and  several  types  of 
cases,  as  the  causes  sufficiently  indicate.  One  variety,  known  as  "serous 
apoplexy  "  by  the  older  writers,  begins,  by  reason  of  a  sudden  effusion, 
very  abruptly,  with  the  phenomena  of  apoplexy  :  there  are  unconscious- 
ness, muscular  resolution,  immobile  pupils,  involuntary  evacuations. 
In  the  midst  of  the  coma  there  may  sometimes  arise  delirium.  So  ex- 
treme mav  be  the  pressure  of  the  fluid  that  the  medulla  oblongata 
ceases  to  functionate,  and  the  patient  dies  in  a  few  hours,  and  rarely 
is  life  prolonged  several  days.  The  next  type  may  be  characterized 
as  the  cofivulsive.  This  begins  with  the  symptoms  of  excitation,  and 
there  may  be  some  f everishness,  headache,  nausea,  and  vomiting,  for  a 
few  days,  when  an  attack  of  eclampsia  occurs,  or  the  convulsion  may 
be  the  initial  symptom,  or  in  adults  a  violent  delirium.  These  symp- 
toms are  soon  followed  by  depression,  and  the  patient  passes  into  a 
stupid,  somnolent  state,  is  roused  with  difficulty,  and  weakness  of  the 
members  is  succeeded  by  complete  paralysis.  Very  unexpectedly,  some- 
times, the  consciousness  revives,  but  for  a  brief  period,  and  the  coma 
comes  on  again,  death  soon  occurring.  This  form  usually  appears  in 
the  course  of  Bright's  disease  or  general  dropsy.  The  ordinary  form 
in  children  sets  in  with  f  everishness,  headache,  intolerance  of  light,  and 
corrugation  of  the  forehead  ;  intolei'ance  of  sounds,  restlessness,  deliri- 
um toward  evening,  wakefulness,  or  disturbed  sleep  ;  vertigo,  twitch- 
ing and  spasmodic  contraction  of  muscles  (head  dra'rni  back,  fingers  and 
toes  incurved)  ;  great  sensitiveness  of  the  skin,  pain  being  caused  by 
a  slight  touch,  esj)ecially  about  the  neck  ;  nausea  and  vomiting  without 
cause,  the  belly  drawn  in,  and  obstinate  constipation.  Such  symptoms 
will  continue  for  several  days,  when  there  will  occur  convulsions  of  an 
epileptiform  character,  or  partial  convulsive  movements  in  an  extremity, 
in  the  muscles  of  the  abdomen,  or  in  the  face.  The  temperature  may 
rise  very  high  during  these  convulsive  attacks — the  pulse  rapid,  and 
often  irregular — but  the  temperature  declines  after  the  eclampsia  has 
ended.  Death  may  take  place  at  this  period,  or,  as  is  most  usual,  the 
epileptiform  attacks  cease  and  the  ordinary  course  of  the  disease  is 
resumed.  The  symptoms  of  depression  now  come  on  :  restlessness  is 
replaced  by  stupor,  rigidity  and  contraction  of  the  muscles  by  paresis, 
heightened  sensibility  by  anaesthesia.  The  piipils  dilate  somewhat 
and  become  less  and  less  mobile,  and  are  often  unequal  in  size,  and 
double  vision  is  noticed.  The  pulse  declines  in  force,  and  exhibits  a 
marked  degree  of  inequality,  now  beating  at  80,  now  at  130.  The  res- 
pirations become  irregular  in  rhythm,  and  manifest  the  Cheyne-Stokes 
type  to  some  extent.  The  surface  becomes  cool  ;  the  fontanelles  are 
prominent  and  rounded  ;  and  the  sutures  in  young  infants  separate 
somewhat.  The  vomiting  continues,  and  the  nutrition  is  greatly  im- 
pau'ed.  The  patient  sinks  into  a  deep  coma,  and,  although  there  oc- 
cur remissions,  in  which  the  unconsciousness  seems  less  profound,  the 


CHRONIC   HYDROCEPHALUS. 


517 


pulse  and  breathing  better,  and  the  reflex  movements  more  easily  ex- 
cited, they  do  not  persist. 

Course,  Duration,  and  Termination. — A  few  cases  have  been  re- 
ported cured.  They  were  milder  examples  of  the  common  type,  as 
seen  in  children,  and,  although  the  symptoms  of  excitation  were  well 
marked,  those  of  depression  did  not  come  on.  The  apj)earances  of 
improvement,  which  are  observed  in  the  stage  of  depression,  are  illu- 
sory. The  apoplectic  and  convulsive  forms  are  always  fatal  in  a  few 
hours  or  two  or  three  days  ;  the  common  form  very  rarely  terminates 
in  recovery.  The  duration  of  the  cases  terminating  by  exhaustion  is 
very  protracted,  reaching  to  four,  six,  even  eight  weeks,  but  the  aver- 
age duration  of  these  cases  is  about  three  weeks.  Those  ending  by 
convulsions  do  not  often  continue  beyond  two  weeks.  The  extended 
duration  of  some  cases  is  due  to  the  absence  of  convulsions  and  the 
prolongation  of  the  stage  of  coma.  As  the  questions  connected  with 
diagnosis  and  treatment  are  the  same  as  for  tubercular  meningitis  and 
for  simple  meningitis,  they  are  postponed  for  separate  and  full  con- 
sideration at  the  conclusion  of  the  subject  of  meningitis. 

CHRONIC   HYDROCEPHALUS. 

Pathogeny  and  Symptoms.  —  Chronic  hydrocephalics,  as  it  occurs 
in  children,  usually  succeeds  to  the  acute  form,  and  is  a  result  of 
rickets,  or  an  accident  of  the  rachitic  constitution.  The  quantity  of 
fluid  is  much  greater,  however,  in  the  acute  form.  After  youth,  the 
accumulation  of  fluid  is  due  to  the  pressure  of  tumors  on  the  straight 
sinus,  vein  of  Galen,  etc.,  and  in  old  age  considerable  eifusion  is  pro- 
duced by  atrophy  of  the  brain.  In  dementia  paralytica,  there  may 
be  considerable  distention  of  the  ventricles  and  of  the  perivascular 
lymph-spaces.  The  initial  symptoms  are  those  of  irritation,  and  are 
due  to  the  presence  of  the  new  vascular  conditions,  but,  as  the  effusion 
grows,  the  neighboring  parts  are  pressed  upon,  and  the  symptoms  of 
depression  then  dominate  the  situation.  Hebetude  of  mind,  stupidity, 
diminished  activity  of  the  special  senses,  and  a  fatuous  expression 
of  countenance,  are  now  observed.  General  sensibility — tactile,  heat, 
cold,  and  sensory — is  much  less  active  than  normal.  Motility  is  also 
impaired,  especially  in  the  distribution  of  the  seventh  nerve  :  there 
are  present  ptosis  and  a  blank  expression  due  to  relaxation  of  the 
muscles  of  expression.  The  pupils  are  unequal,  and  respond  slug- 
gishly to  the  action  of  light.  The  tongue  is  paretic,  and  the  speech 
thick  and  utterly  unintelligible.  The  faculties  continuously  decline 
into  idiocy  or  dementia  ;  locomotion  becomes  impossible  ;  control  of 
the  sphincters  is  lost  ;  sight  and  hearing  are  abolished.  This  slow 
decline  may  be  diversified  by  convulsive  seizures,  or  more  acute 
symptoms  may  be  produced  by  a  sudden  and  large  effusion.     In  the 


518  DISEASES  OF  THE  NERVOUS  SYSTEM. 

latter,  unconsciousness  may  occur,  preceded  by  violent  headache,  and 
followed  by  inequality  of  pupils,  hemiplegia  more  or  less  complete, 
slow,  irregular  pulse,  impaired  articulation,  aphasia,  etc.  The  dura- 
tion of  the  cases  is  measured  by  months,  and  the  termination  is  fatal. 
The  fatal  result  may  be  caused  by  the  ordinary  progress  of  the  dis- 
ease— the  compression  of  the  increasing  effusion,  or  by  some  intercur- 
rent disease,  as  pneumonia,  pleuritis,  meningitis,  etc.  The  treatment 
is  the  same  as  for  the  congenital  form,  to  which  the  reader  is  referred. 


CONGENITAL  HYDROCEPHALUS. 

Causes. — Much  obscurity  obtains  on  this  point.  Imperfect  formation 
of  the  cranium  and  defective  development  of  the  brain  are  influential 
causes.  A  chronic  inflammation  of  the  epandyma  seems  to  develop 
the  disease  sometimes.  Again,  it  is  the  product  of  purely  mechanical 
agencies,  such  as  the  compression,  by  a  tumor,  of  the  straight  sinus  or 
of  the  vena  Galeni. 

Pathological  Anatomy. — There  is  no  constant  ratio  between  the  size 
of  the  head  and  the  amount  of  liquid  present.  The  fluid  may  vary 
from  an  ounce  or  two  to  sixteen  ounces  or  more.  The  liquid  is  trans- 
parent, of  a  straw-color,  and  contains  but  little  solid  matter,  which 
consists  of  albumen  and  chloride  of  sodium.  If  the  fluid  is  consider- 
able, the  ventricles  are  much  distended,  the  optic  thalami  and  the  cor- 
pora striata  are  depressed  and  flattened,  the  orifice  between  the  two 
ventricles  is  very  large,  and  the  roof  of  the  ventricles  is  thinned  ac- 
cording to  the  amount  of  fluid,  and  may  be  to  the  extent  that  only  a 
mere  line  of  white  and  gray  matter  remains.  From  this  extreme  dis- 
tention to  the  mere  filling  of  the  ventricles  without  disturbing  the 
harmony  and  proportion  of  parts,  there  are  numerous  variations  in  the 
quantity  of  fluid.  The  enlargement  of  the  head  caused  by  the  effusion 
may  be  sufiicient  before  bii'th  to  impede  or  prevent  natural  delivery. 
The  degree  of  ossiflcation  is  an  important  element  in  the  dimensions. 
The  bones  are  so  thinned  as  to  be  translucent  ;  the  fontanelles  and  the 
spaces  between  the  sutures  are  very  wide  ;  the  lateral  portions  of  the 
cranium  project  greatly  ;  the  forehead  bulges  out  enonnously  over  the 
eyes  ;  the  orbital  plates  are  depressed,  whence  the  eyes  are  forced  for- 
ward between  the  lids,  producing  the  condition  of  exophthalmus. 

Symptoms. — The  dimensions  of  the  head  at  first  attract  attention  to 
the  condition  of  the  infant.  At  the  period  when  the  head  should  be 
held  erect  it  is  found  to  droop,  resting  on  one  or  the  other  shoulder. 
Then  it  is  noticed  that  the  mental  development  does  not  grow  with  the 
physical ;  that  the  face  is  devoid  of  expression  ;  that  the  attention  is 
not  attracted  by  surrounding  objects  ;  that  voluntary  movements  are 
slow  of  execution.  When  the  period  for  standing  on  the  feet  and 
making  attempts  at  walking  arrives,  the  power  to  maintain  the  erect 


CONGENITAL   HYDROCEPHALUS.  519 

posture  is  wanting.  The  general  condition  is  not  favorable,  and 
although  the  appetite  may  be  keen,  even  voracious,  the  assimilation  is 
not  equal  to  the  preparation  of  the  aliment.  The  face  has  a  rather  old 
look,  and  is  wrinkled  ;  the  voice  is  feeble  and  sibilant.  Some  of  these 
subjects  are,  however,  capable  of  slight  mental  development,  but  they 
do  not  acquire  any  higher  capacity  for  speech  than  the  automatic  use 
of  a  few  words,  and,  if  they  reach  manhood,  the  mental  powers  are  only 
those  of  a  child,  the  voice  having  the  same  characteristics.  As  regards 
the  special  senses,  odor  and  taste  are  more  often  preserved,  while  hear- 
ing is  imperfect.  Disorders  of  vision  and  of  the  cutaneous  sensibility 
are  common.  Numbness,  tingling,  and  pains  are  felt  in  the  extremi- 
ties. Motility  is  impaired  to  a  less  or  greater  extent.  There  may  be 
a  general  paresis,  which  is  more  pronounced  in  one  member,  but  rarely 
complete  paralysis.  There  are  great  differences  in  the  cases  :  some 
can  not  stand  without  support  ;  others  walk,  but  the  gait  is  hesitating  ; 
they  stumble  at  every  obstacle,  and  seem  constantly  to  be  about  to  pitch 
forward,  owing  to  the  weight  of  the  head.  Epileptiform  attacks  occur 
in  many  of  the  cases  from  time  to  time.  The  nutrition  is  bad,  not- 
withstanding a  voracious  appetite  ;  they  suffer  from  constipation,  and 
have  an  excessive  flow  of  saliva  from  the  mouth  ;  the  skin  is  dry  and 
the  eyelids  are  puffy.  If  the  anterior  fontanelle  is  very  large,  strong 
compression  will  put  the  patient  into  a  somnolent,  even  a  comatose  state. 

Course,  Duration,  and  Termination. — The  course  of  the  disease  is 
chronic,  its  march  irregular.  At  times  considerable  progress  is  made  ; 
then  the  case  remains  stationary  for  some  time,  even  for  years.  A 
majority  of  the  cases  terminate  within  the  first  year  ;  others  are  pro- 
longed to  the  fifteenth  year,  even  beyond  this.  The  more  voluminous 
the  head,  the  more  rapid  the  progress  of  the  case,  as  a  rule.  Sponta- 
neous cures  have  been  effected  by  the  discharge  of  the  liquid,  either 
by  a  wound  or  through  the  nose.  Cures  may  be  effected  in  slight 
cases  when  recognized  early,  but  such  a  result  is  exceptional,  the  usual 
termination  being  death.  The  fatal  result  is  reached  by  convulsions 
and  coma,  unless  cut  off  by  intercurrent  diseases. 

Treatment. — The  author  has  had  good  results  from  the  use  of  iodide 
of  potassium,  but  it  was  a  case  of  effusion  probably,  limited  to  the  ven- 
tricles. Flying-blisters,  the  internal  administration  of  digitalis,  ergot, 
and  purgatives,  with  the  occasional  use  of  iodide  of  potassium,  carried 
to  slight  iodism,  are  the  remedies  best  adapted  to  the  cases  of  slight 
extent,  which  may  be  conducted  to  a  favorable  termination.  The  use 
of  the  finest  aspirator-needle  may  now  be  justified,  in  view  of  the  spon- 
taneous cures  which  have  followed  accidental  discharge  of  the  fluid. 
Care  being  taken  to  avoid  the  longitudinal  sinus,  the  ventricle  may  be 
entered  with  safety,  and  the  operation  is  easily  performed.  When  suf- 
ficient fluid  is  withdrawn,  the  cranium  should  be  gently  but  firmly  com- 
pressed. 


520  DISEASES   or   THE  NERVOUS   SYSTEM. 


TUBERCULAR  MENINGITIS. 

Definition, — By  this  term  is  meant  an  inflammation  of  the  cerebral 
meninges,  caused  by  the  presence  of  tubercular  granulations. 

Causes. — Tubercular  meningitis  occurs  most  frequently  in  children 
from  two  to  six  years  of  age,  and  in  adults  from  twenty  to  thirty  years, 
and  is  about  equally  distributed  between  the  sexes.  Children  of  the 
well-to-do  classes  are  apt  to  suffer  from  this  disease,  and  those  whose 
nervous  system  preponderates  over  the  digestive  and  muscular.  The 
"  gelatinous  children  of  albuminous  parents,"  as  the  phrase  goes,  pos- 
sess a  special  susceptibility  to  tubercular  meningitis — the  pale,  thin- 
skinned,  blue-eyed,  precocious  children  of  pale,  flabby,  and  delicate 
parents.  The  changeable  weather  of  winter  and  spring  disposes  to  the 
development  of  the  disease.  All  the  circumstances  comprehended  in 
the  term  had  hygiene  promote  the  occurrence  of  this  malady,  especially 
insuflicient  light,  bad  air,  and  improper  food.  None  of  these  causes 
could  produce  this  disease  in  the  absence  of  the  tubercular  matter.  It 
is  extremely  rare  to  find  the  tubercular  deposits  limited  to  the  pia 
mater — in  thirty-eight  examples  of  the  disease  there  were  but  two  in 
which  the  deposit  was  thus  limited  (Jaccoud).  Tubercular  meningitis 
is  transmitted  by  inheritance  in  the  limited  sense  that  the  diathesis  is 
inherited  :  in  one  member  of  a  family  so  tainted  it  may  be  meningitis, 
in  another  phthisis,  in  a  third  ulceration  of  the  intestine. 

Pathological  Anatomy. — Miliary  tubercles,  in  the  form  of  grayish- 
white  granules  having  a  translucent  and  somewhat  gelatinous  appear- 
ance, are  distributed  along  the  vessels  of  the  pia  mater.  These  miliary 
granules  vary  in  size  from  a  minute  object  just  visible  to  the  eye  up  to 
a  large  pin's-head,  and  these  aggregating  in  a  mass  form  a  tubercle  as 
big  as  a  pea.  The  distribution  of  the  tubercle-granules  is  not  the 
same  in  all  situations  :  it  may  be  greater  in  the  neighborhood  of  the 
arteries  of  the  base  (basal  meningitis)  or  the  arteries  of  the  convexity  ; 
again,  the  principal  deposits  may  be  in  the  pia  of  the  frontal  or  of  the 
parietal  regions.  There  may  be  but  few  tubercles  in  any  situation  in 
some  cases  ;  in  others  the  whole  membrane  may  be  thickly  studded 
with  them.  The  intensity  of  the  inflammation  does  not  have  a  con- 
stant relation  to  the  number  of  tubercles,  for  the  inflammation  may  be 
great  with  few  tubercles,  and  slight  with  a  large  crop  of  tubercles. 
Besides  tubercle  there  are  present  the  evidences  of  suppuration  in  a 
sero-purulent  effusion,  seen  along  the  course  of  the  vessels  especially, 
as  "yellowish  stripes"  (Rindfleisch).  The  pia  mater  at  the  base  is 
thickly  covered  with  a  gelatinous  exudation,  and  the  membrane  itself 
is  thickened  and  opaque,  especially  about  the  optic  chiasm  and  the  an- 
terior perforated  space  extending  up  into  the  fissure  of  Sylvius.  There 
is  more  or  less  effusion  usually  in  the  ventricles,  and  the  plexus  cho- 
roides  is  the  seat  of  an  extreme  hyjjersemia.    More  or  less  oedema  of  the 


TUBERCULAR   MENINGITIS.  521 

cortex  takes  place,  provided  there  is  no  effusion,  but  when  there  is  effu- 
sion the  cerebral  substance  is  dry  and  anaemic  from  pressure.  Miliary 
tubercles  are  also  found  in  the  cortex,  and  migrated  white  corpus- 
cles are  abundantly  distributed  through  the  cerebral  tissues.  The  mil- 
iary tubercles,  aggregated  in  masses,  are  found  in  many  situations  to 
have  undergone  caseous  or  fatty  transformation.  Tubercles  are  also 
widely  distributed  throughout  the  body. 

Symptoms.  — There  is  a  period  during  which  it  is  probable  tuber- 
cular deposit  is  taking  place,  manifested  by  symptoms  which  may  be 
justly  called  prodromal.  The  disturbances  resulting  in  the  symptoms 
of  the  disease  are  produced  by  the  inflammation  which  is  excited  by 
the  tubercular  deposit.  The  prodromal  symptoms  are  chiefly  those  in- 
dicative of  failure  of  nutrition  ;  emaciation  goes  on,  and  the  strength 
declines  proportionally  ;  the  appetite  fails,  and  the  character  changes, 
the  patient  becoming  irritable  and  morose.  The  child,  before  preco- 
cious and  vivacious,  becomes  indifferent  to  former  occupations  and 
amusements.  Sleep  is  disturbed  by  vivid  dreams  ;  the  child  grinds  its 
teeth,  cries  out  suddenly  in  the  night,  and  walks  about  in  a  somnam- 
bulistic state.  The  digestive  organs  become  disordered,  the  belly  is 
swollen,  diarrhoea  alternates  with  constipation,  and  vomiting  occurs 
without  cause,  without  the  presence  of  indigestible  matters  to  excite  it. 
Headache  is  complained  of,  vertigo  is  experienced  in  rising  up  to  walk 
or  in  lying  down,  and  pains  are  felt  in  the  limbs.  The  ominous  symp- 
tom of  double  vision  is  sometimes  observed  at  this  period.  The  author 
has  heard  a  precocious  little  boy  say  during  this  prodromal  period,  "  I 
see  two  mammas,"  several  weeks  before  the  developed  disease  came 
on.  The  stage  of  excitation  symptoms  appears  in  from  two  days  to  six 
weeks,  even  longer,  of  the  prodromal  period.  Fever  begins  ;  the  tem- 
perature rises  to  102°  or  103°  Fahr,  in  the  evening,  and  falls  in  the 
morning  to  99°  ;  the  pulse  varies  greatly,  going  up  to  130,  140,  and 
falling  to  80,  In  adults  this  fever  of  the  excitation  period  may  be 
wanting.  At  all  times  during  the  disease  the  pulse  is  very  unequal  in 
rhythm  and  the  heart  veVy  excitable.  The  pulse  may  become  slow  and 
regular  without  any  apparent  reason,  or  may  again  become  very  rapid. 
Although  the  type  of  the  fever  is  remittent  and  is  often  mistaken  for 
remittent  fever,  it  is  subject  to  great  variations.  Three  important 
symptoms  besides  the  fever  mark  the  onset  of  the  excitation  period — 
headache,  vomiting,  and  constipation.  The  headache  is  severe,  heavy,  or 
lancinating  ;  and,  although  continuous,  is  varied  by  exacerbations,  com- 
pelling outcries,  or  rubbing  the  head,  or  other  manifestations  of  severe 
suffering.  As  the  suffering  is  increased  by  light,  the  head  is  either 
buried  in  the  bedclothes  or  turned  to  the  wall,  or  the  eyes  are  covered 
by  the  eyelids.  The  vomiting  occurs  a  few  times  during  the  twenty- 
four  hours,  and  is  always  without  apparent  cause  ;  the  constipation 
persists  obstinately  ;  the  belly  is  hard  and  retracted.    During  the  exci- 


522  DISEASES   OF   THE   NERVOUS   SYSTEM. 

tation  period,  changes  in  the  character  and  disposition  which  began  in 
the  prodromal  period  continue  and  are  more  pronounced — an  exceeding 
fretfulness  and  hostility  to  those  to  whom  they  were  much  attached, 
developing.  Not  only  the  special  but  general  sensibility  is  exalted  ; 
all  movements  cause  pain  and  loud  expressions  of  suffering,  and  the 
least  pinch,  especially  about  the  neck,  excites  exquisite  pain.  In  the 
motor  sphere  the  symptoms  of  excitation  take  the  form  of  spasmodic 
movements  of  muscles,  contractions,  and  rigidity,  especially  seen  in  the 
muscles  of  the  members  and  of  the  neck.  There  will  occur  at  this 
period  also  local  convulsive  movements,  and  not  unfrequently  general 
convulsions  (eclampsia),  with  the  usual  phenomena.  The  stage  of 
excitation  due  to  the  development  of  meningitis  now  begins  to  yield 
to  the  phenomena  of  depression  due  to  the  pressure  of  the  fluid  on  the 
cerebral  matter.  Here,  then,  is  a  period  during  which  the  symptoms 
of  irritation  still  linger,  and  the  symptoms  of  depression  are  just  mani- 
festing themselves — a  mixed  stage  :  paroxysms  of  pain  and  spasmodic 
and  convulsive  attacks  are  separated  by  periods  of  somnolence,  during 
which  there  may  be  uttered  the  peculiar  shrill,  unearthly  cry  or  shriek 
called  the  hydrocephalic  cry.  If  attempts  at  walking  are  now  made, 
the  patient's  movements  are  incoordinate  and  uncertain,  and  indeed 
it  is  impossible  to  preserve  the  equilibrium.  Torpor  now  becomes  the 
settled  state,  but  still  the  patient  can  be  roused  to  make  an  imperfect 
or  monosyllabic  reply  to  questions,  lapsing  back  into  a  somnolent  state 
as  soon  as  the  attention  is  no  longer  attracted.  At  this  period  the 
ocular  changes  are  manifest  :  there  are  strabismus  and  double  vision  ; 
the  pupils  are  often  unequal.  The  countenance  is  pale,  stolid,  and 
expressionless.  The  retinal  changes  are  very  pronounced.  Tubercles 
of  the  choroid  can  often  be  detected.  At  first  the  optic  papillae  are 
swollen,  blurred,  and  indistinct,  the  veins  are  enlarged  and  tortuous  ; 
but  in  the  further  progress  of  the  case  retrograde  changes,  ending  in 
white  atrophy  of  the  disks,  take  place.*  This  mixed  stage  has  a 
variable  duration  of  a  few  days  to  a  week  or  more,  and  is  varied  by 
illusory  evidences  of  improvement,  which  ofte'n  mislead  the  physician, 
and  raise  false  hopes  in  the  minds  of  the  parents  and  friends.  These 
appearances  of  improvement  at  this  time  consist  in  a  more  regular 
pulse,  less  somnolence,  greater  interest  and  attention  to  surrounding 
objects,  playthings,  etc.  Indeed,  it  seems  as  if  the  morbid  process  were 
arrested,  and  that  convalescence  is  about  to  be  established  ;  but,  while 
the  most  cheerful  anticipations  are  indulged  in,  formidable  symptoms 
suddenly  appear,  A  general  convulsion,  it  may  be,  occurs,  or  the  mus- 
cles of  the  neck  and  spine  become  rigid,  or  local  convulsions  affect  the 
members  ;  a  mild  delirium  manifests  itself  ;  the  respiratory  move- 
ments become  very  unequal  in  depth  and  irregular  in  rhythm,  and 

*  Allbutt  oil  "  The  Ophthalmoscope,"  p.  112. 


TUBERCULAR   MENINGITIS.  523 

have  at  times  a  sighing  character  ;  the  pulse  is  equally  irregular,  be- 
comes slow,  falling  to  fifty  even,  and  there  are  marked  variations  in 
its  volume  and  tension  ;  the  temperature  remains  elevated,  but  pre- 
serves its  remittent  type.  The  approaching  stage  of  depression  is  now 
announced  by  the  increasing  somnolence,  by  the  greater  effort  to  excite 
the  most  transient  and  indefinite  response  ;  light  nor  sounds  no  longer 
disturb  the  brain  ;  sensibility  is  no  longer  excitable  ;  the  contractions 
of  muscles  are  replaced  by  relaxation  ;  the  urine  is  passed  involun- 
tarily. When  the  stage  of  depression  is  fully  established,  no  indica- 
tion of  consciousness  can  be  excited  by  any  irritation,  and  the  reflex 
movements  of  the  eye  are  entirely  abolished.  The  pupils  now  dilate  ; 
the  upper  lids  droop  over  the  eyes  ;  the  globe  of  the  eye  rolls  from 
side  to  side  (nystagmus)  ;  the  pharynx  becomes  less  and  less  respon- 
sive to  the  presence  of  food  or  drink,  and  finally  no  movements  can 
be  excited — only  the  slow,  irregular  pulse  changing  to  a  rapid  and 
feeble  pulse  and  the  Cheyne-Stokes  breathing  manifest  the  signs  of 
functional  action.  Males  from  accumulating  mucus  now  obstruct  the 
breathing,  the  pulse  becomes  more  rapid  and  feeble,  a  cold  sweat 
breaks  out  on  the  skin,  the  abdomen  becomes  full  and  prominent,  the 
evacuations  are  relaxed  and  involuntary,  and  death  occurs  at  last  by 
protracted  failure  of  respiration  or  by  a  convulsion. 

Course,  Duration,  and  Termination. — The  division  into  periods  is 
an  arbitrary  arrangement,  but  useful  as  a  means  of  indicating  the 
variability  of  the  symptoms  and  their  relation  to  the  morbid  process. 
But  the  course  of  the  disease  is  not  always  that  above  indicated  :  there 
are  variations  due  to  the  age  of  the  subject ;  and  tubercular  meningitis, 
as  a  secondary  disease,  differs  from  the  primary  affection.  In  acute 
tuberculosis  the  cerebral  symptoms  are  pronounced,  but  they  are  not 
those  of  tubercular  meningitis.  The  form  of  the  disease  occurring  in 
adults  is  secondary,  usually  to  advanced  pulmonary  tuberculosis. 
There  are  no  prodromal  symptoms.  In  the  midst  of  a  pulmonary 
disease,  the  patient  experiences  intense  headache,  vertigo,  delirium, 
often  of  a  maniacal  character  ;  there  occur  contractions  of  muscles, 
followed  by  paresis  ;  irregularity  of  pulse  and  respiration  is  noted ; 
and  coma  and  insensibility  succeed  to  wakefulness  and  delirium.  Con- 
vulsions do  not  occur  in  the  course  of  this  secondary  meningitis  in 
adults. 

The  prodromal  period  in  the  ordinary  form  of  the  disease  has  no 
fixed  duration,  and  may  continue  for  three  months  ;  it  is  usually  about 
three  weeks,  and  is  probably  never  absent  if  carefully  inquired  into. 
The  period  of  excitation  has  a  duration  of  about  one  week  to  two 
weeks  ;  the  middle  period  may  be  protracted  three  weeks,  but  usually 
occupies  one  week  ;  the  period  of  depression  lasts  from  one  to  two 
weeks.  Although  a  very  few  cases  have  been  reported  cured,  it  is 
held  to  be  an  incurable  disease,  and  the  termination  fatal.     The  cases 


524  DISEASES   OF   THE   NERVOUS   SYSTEM. 

reported  cured  were,  it  is  generally  supposed,  examples  of  simple  not 
tubercular  meningitis.  The  consideration  of  diagnosis  and  treatment 
will  be  taken  up  after  the  study  of  simple  meningitis  of  the  base  and 
convexity. 

ACUTE   MENINGITIS. 

Definition. — Acute  meningitis  consists  in  an  inflammation  of  the 
pia  mater  and  arachnoid,  chiefly  the  former.  It  may  be  limited  to  the 
base — basilar  meningitis,  or  to  the  convexity — meningitis  of  the  con- 
vexity. 

Causes. — Meningitis  is  derived  by  contiguity  of  tissue  from  disease 
in  neighboring  parts— disease  of  the  internal  ear,  erysipelas  of  the  face, 
malignant  pustule,  caries  of  the  bones,  traumatic  injuries.  It  is  then 
entitled  secondary  meningitis.  It  sometimes  arises  during  the  course  of 
inflammation  of  serous  membranes,  acute  rheumatism,  puerperal  fever, 
pyaemia,  Bright's  disease,  by  that  which  was  formerly  called  a  metas- 
tasis, and  hence  was  designated  metastatic  m,eningitis.  The  primary 
form  with  which  we  are  now  chiefly  concerned  arises  from  the  causes 
inducing  congestion  and  overaction  of  the  brain,  as  excessive  intel- 
lectual effort,  prolonged  wakefulness,  exposure  to  the  direct  rays  of  the 
sun,  and  alcoholic  excess.  The  most  common  cause  of  meningitis  is  the 
deposit  of  tubercle,  but  this  has  been  discussed  in  the  previous  chapter. 
The  primary  form  is  a  rather  uncommon  malady.  The  disease  is  more 
frequent  in  men  than  in  women,  and  is  less  common  in  children. 

Pathological  Anatomy. — In  the  basilar  form,  the  inflammatory 
changes  are  confined  to  the  base,  and  consist  of  intense  hypersemia, 
followed  by  purulent  and  fibrinous  exudation,  covering  the  parts  at 
the  base  as  far  back  as  the  ]Dons,  and  forward  to  the  optic  chiasm,  and 
surrounding  some  of  the  nerves.  The  choroid  plexus  is  intensely  hy- 
peraemic,  and  the  ventricles  may  be  distended  with  fluid,  compressing 
the  hemispheres  and  flattening  the  convolutions.  The  ependyma  of 
the  ventricles  becomes  granular  or  undergoes  thickening.  Hydrocepha- 
lus is  by  no  means  present  in  all  cases.  In  the  meningitis  of  pyaemia 
and  other  septic  maladies  the  fluid  exuded  is  largely  purulent,  and  mi- 
grating white  corpuscles  are  found  in  great  numbers  in  the  exudation 
in  the  ventricles.  In  meningitis  of  the  convexity  the  inflammation 
is  excited  by  extension  from  the  bones  of  the  cranium,  from  caries 
of  the  petrous  portion,  from  panophthalmitis,  from  erysipelas  of  the 
head,  and  carbuncle  of  the  upper  lip,  etc.,  and  is  of  the  character 
manifested  by  the  same  process  at  the  base.  Pus  is  extensively  infil- 
trated, especially  along  the  course  of  the  great  vessels.  The  migrating 
white  corpuscles  invade  the  gray  matter  of  the  cortex,  and  pus-cells 
are  contained  in  the  fluid  of  the  ventricles  in  large  numbers.  Although 
the  morbid  process  may  be  confined  to  the  convexity,  yet  in  most 
cases  the  base  is  more  or  less  invaded. 


ACUTE   MENINGITIS.  525 

Symptoms  — There  may  or  may  not  be  a  prodromal  period,  charac- 
terized by  a  rather  violent  headache,  vertigo,  and  cerebral  vomiting, 
lasting  for  a  few  hours  or  a  day  or  two.  The  real  onset  of  the  disease 
is  rather  sudden,  and,  like  other  acute  inflammatory  diseases,  begins 
with  a  decided  chill  followed  by  high  fever — by  a  more  intense  and 
sustained  fever  than  in  other  cerebral  maladies.  The  pulse  may  be 
100,  the  temperature  103°  or  104°  Fahr.  The  face  is  flushed,  the  eyes 
are  injected  and  swollen.  There  are  from  the  beginning  an  intense 
headache,  vertigo,  nausea,  and  vomiting.  When  the  morbid  process 
is  confined  to  the  base,  the  mental  symptoms  may  be  very  insignifi- 
cant, and  consist  of  confusion  of  mind,  or  mild  delirium  toward  even- 
ing or  on  awaking  from  sleep,  but  usually  there  are  hallucinations  and 
illusions,  active  delirium,  sometimes  furious  and  maniacal,  and  these 
are  proper  to  meningitis  of  the  convexity.  Dui-ing  the  period  of  exci- 
tation there  are  hyperaesthesia  of  the  skin  and  contractions  and  spasms 
of  the  muscles  of  the  extremities,  and  those  innervated  by  the  cranial 
nerves — hence  the  ocular  defects  and  disturbances,  twitchings  of  the 
facial  muscles,  rigidity  and  contraction  of  the  spinal  and  cervical  mus- 
cles, etc.  The  symptoms  of  excitation  are  soon  succeeded  by  depres- 
sion. Early,  besides  the  muscular  incoordination  and  consequent  ataxic 
aphasia,  there  occurs  a  true  aphasia  from  deposits  along  the  middle 
cerebral  and  consequent  compression  of  the  supposed  language  center. 
Delirium  is  succeeded  by  somnolence,  gradually  deepening  into  coma  ; 
exalted  sensibility  (hyperaesthesia)  yields  to  loss  of  the  senses  of  touch 
and  pain  ;  spasms  and  contractions  of  muscles  are  replaced  by  paraly- 
sis. The  pupil  dilates.  Early  in  the  disease  ophthalmoscopic  exami- 
nation discloses  choked  disks  and  swollen  veins,  but  the  papillae  rap- 
idly undergo  atrophy.  The  eyelids  drop  down  upon  the  eyes,  and  are 
swollen  and  prominent  ;  epistaxis  often  occurs.  With  the  increasing 
pressure  on  the  medulla  oblongata,  the  pulse  falls,  then  grows  rapid 
and  feeble,  but  the  temperature  continues  at  103°  or  104°  Fahr.  The 
respiration  becomes  irregular,  sighing — of  the  Cheyne-Stokes  type — 
and  increasingly  shallow. 

Course,  Duration,  and  Termination. — The  cases  of  meningitis  pre- 
sent great  variability  in  their  course  and  in  their  duration  :  some  are 
characterized  by  remissions — apparent  improvement  continuing  for 
days,  and  followed  by  relapses.  Again,  the  course  and  duration  of 
other  cases  are  much  affected  by  the  cause  of  the  meningitis  and  the 
character  of  the  coexistent  malady.  The  duration  may  be  stated  as 
varying  from  one  week  to  eight  weeks.  The  usual  termination  is  in 
death.  Cures  may  be  effected  in  which  permanent  damage  has  hap- 
pened, and  a  sense  or  a  member  remains  only  partly  capable  of  func- 
tion ever  after.  Perfect  cures  have  been  reported,  but  a  doubt  of 
their  genuineness  must  always  be  entertained.  Before  and  immediate- 
ly succeeding  death  the  temperature  may  rise  to  105°  and  106°  Fahr. 


526  DISEASES   OF   THE  NERVOUS   SYSTEM. 

Diagnosis. — This  question  includes  tlie  differentiation  of  the  several 
forms  of  meningitis,  and  the  separation  of  meningitis  from  acute  tu- 
berculosis, typhoid  fever,  tumor  and  abscess  of  the  brain,  encephalitis, 
cerebral  hypersemia,  uraemia,  and  disease  of  the  labyrinth.  Tubercu- 
lar meningitis  is  differentiated  from  the  other  forms  by  the  history, 
by  the  simultaneous  appearance  of  tubercular  deposit  in  other  brgans, 
especially  pulmonary  tuberculosis,  and  by  the  presence  of  tubercles  in 
the  choroid.  Acute  hydrocephalus  is  distinguished  from  meningitis 
by  the  less  degree  of  fever,  by  the  predominance  of  the  stage  of  de- 
pression, and,  in  the  apoplectic  and  convulsive  forms,  by  its  more 
speedy  termination,  and  by  the  absence  of  symptoms  due  to  the  impli- 
cation of  the  cranial  nerves  at  the  base.  Meningitis  in  its  various 
forms  is  distinguished  from  acute  tuberculosis  and  typhoid  fever  by 
the  symptoms  of  excitation  of  the  brain,  especially  the  convulsions, 
and  subsequently  by  the  ocular  and  other  paralyses,  the  alterations  of 
the  retina,  by  the  absence  of  the  rose-spots,  the  absence  of  diarrhcea, 
and  the  presence  of  constipation.  Meningitis  is  distinguished  from 
tumors  of  the  brain  by  its  more  rapid  progress,  more  diffused  symp- 
toms, and  the  presence  of  fever  ;  from  abscess,  by  the  absence  of  a 
period  of  latency  after  the  symptoms  of  an  inflammation  ;  and  by  the 
diffusion  of  the  symptoms  of  depression.  From  cerebral  hyperaeraia, 
meningitis  is  differentiated  by  the  higher  temperature,  longer  dura- 
tion, and  the  symptoms  of  depression  succeeding  to  a  stage  of  excita- 
tion. In  uraemia  the  temperature  is  usually  below  rather  than  above 
normal ;  the  urine  is  scanty  and  contains  albumen,  and  there  is  or  has 
been  dropsy.  Labyrinthine  disease,  even  inflammation  of  the  middle 
ear,  may  closely  simulate  meningitis,  but  the  existence  of  ear-symp- 
toms and  the  absence  of  paralysis  indicate  the  source  of  the  symp- 
toms, which  also  begin  with  great  violence. 

Treatment. — The  head  should  be  kept  elevated ;  the  room  dark  and 
quiet,  to  exclude  all  sources  of  cerebral  excitement.  An  ice-bag  should 
be  put  to  the  head,  the  hair  being  previously  removed.  If  a  robust 
subject,  leeches  should  be  applied  to  the  mastoid  bone  and  to  the  nape 
of  the  neck.  An  active  purgative  should  be  administered  at  the  out- 
set. If  the  temperature  is  high,  the  wet-sheet  should  be  used  two  or 
three  times  a  day,  unless  mental  excitement  is  produced  by  it.  If  the 
patient  is  calm  under  its  use,  and  if  the  temperature  is  lowered  by  it, 
the  best  results  may  be  expected  from  it.  The  author  has  witnessed 
admirable  results  from  the  administration  of  the  tincture  of  aconite- 
root  (two  drops)  and  the  deodorized  tincture  of  opium  (five  drops) 
every  two  hours  during  the  stage  of  excitation.  Bromide  of  potas- 
sium (  3  ss.)  and  fluid  extract  of  ergot  (  3  ss.),  every  four  hours,  are 
appropriate  remedies  to  diminish  the  vascular  excitement,  but,  in  the 
author's  experience,  are  not  so  successful  as  aconite  and  opium.  If 
there  be  much  cerebral  excitement,  good  results  are  obtained  from  the 


CHRONIC   MENINGITIS.  527 

fluid  extract  of  gelsemiura,  which  may  be  added  to  the  other  remedies 
(trij  every  two  hours).  If  the  convulsions  are  numerous,  bromide  of 
potassium  must  be  administered  freely.  During  the  whole  duration 
of  the  disease  up  to  coma,  Lugol's  solution  (four  to  ten  drops  ter  in 
die)  should  be  administered,  or  the  iodide  of  potassium  if  better 
borne.  This  remedy  is  especially  serviceable  in  the  tubercular  form. 
During  the  stage  of  excitation,  mustard-plasters  should  be  applied  to 
the  forehead  and  neck  several  times  a  day,  allowing  them  to  remain 
on  but  a  minute,  or  even  less,  until  slight  rubefaction  is  produced. 
The  author  must  decidedly  condemn  the  practice  of  severe  and  pro- 
tracted counter-irritation  so  often  pursued  in  cerebral  maladies.  The 
remedies  above  advised  must  be  discontinued  when  dejDression  of  func- 
tion occurs — except  the  iodine  solution  or  iodide  of  potassium.  The 
best  results  are  then  obtained  by  small  doses  of  quinia,  with  belladonna 
tincture  or  extract  (two  grains  of  quinia  and  one  sixth  grain  of  bella- 
donna extract  every  three  hours).  An  occasional  or  spasmodic  ad- 
ministration of  these  remedies  will  not  suffice — they  must  be  persisted 
in.  During  this  period  careful  alimentation  is  very  necessary,  and 
wine  may  be  sometimes  very  serviceable,  but  its  administration  must 
be  watched.  The  author  feels  it  his  duty  to  condemn  the  use  of  mer- 
cury in  this  disease.  Experience  has  shown  that  it  has  no  power  to 
check  the  inflammation,  and  ptyalism  enhances  all  the  dangers. 


CHRONIC   MENINGITIS. 

Pathogeny. —  Chronic  meningitis  is  characterized  by  the  formation 
of  membranous  exudation,  opacities  of  the  arachnoid,  adhesions  be- 
tween the  arachnoid  and  pia,  and  such  firm  attachment  of  the  mem- 
branes to  the  brain  that,  in  detaching  them,  the  brain  is  torn.  The 
morbid  changes  in  the  membranes,  the  formation  of  neo-membrane,  etc., 
take  place  both  at  the  convexity  and  at  the  base.  In  the  latter  situa- 
tion the  cranial  nerves  are  impinged  on  with  the  effect,  first,  of  causing 
irritation,  shown  in  pain  and  spasm  of  these  nerves  at  their  peripheral 
distribution  ;  and,  second,  loss  or  depression  in  function,  exhibited  in 
anaesthesia  and  motor  paralysis.  The  lesions  of  chronic  meningitis  are 
found  in  old  cases  of  mania,  dementia,  and  dementia  paralytica.  The 
only  causes  known  to  have  an  effect  in  producing  this  disease  are  in- 
juries of  the  head,  chronic  alcoholism,  and  heredity. 

Symptoms. — So  often  associated  with  the  mental  disorders  above 
mentioned,  chronic  meningitis  is  obscured  and  overlooked  in  the  more 
pronounced  symptoms  of  the  associated  malady.  There  are,  neces- 
sarily, two  classes  of  symptoms  to  be  noted — those  of  irritation,  those 
of  depression  :  the  former  mean  pain,  spasm,  or  contraction  ;  the  latter 
anaesthesia  and  paralysis.  In  the  first  group  are  headache,  tinnitus 
aurium^  vertigo,  double  vision,  rigidity  and  contraction  of  the  muscles 


528  DISEASES   OF   THE   NERVOUS   SYSTEM. 

of  the  neck  and  spine,  nausea  and  vomiting,  irregular  pulse,  and  rhyth- 
mic breathing  ;  in  the  second,  impaired  mind,  defects  of  speech,  or 
aphasia,  amaurosis  (double  optic  neuritis),  weakness,  paresis,  or  paraly- 
sis of  members  or  of  groups  of  muscles,  weak  pulse,  and  sighing,  shal- 
low, irregular  breathing,  paralysis  of  tongue,  and  paresis  of  pharynx, 
etc.  The  treatment  is  that  of  the  acute  form,  except  the  use  of  the 
arterial  sedatives. 


ACUTE   ENCEPHALITIS— ABSCESS  OF  THE   BRAIN. 

Definition. — By  acute  encephalitis  is  meant  a  suppurative  inflamma- 
tion of  the  brain,  and  which  is  localized,  not  diffused.  It  may  be  pri- 
mary  or  secondary. 

Causes. — Notwithstanding  certain  stimuli,  long  acting,  have  been 
supposed  to  cause  inflammation  of  the  brain,  the  facts  do  not  warrant 
this  supposition.  These  supposed  causes  are,  prolonged  mental  effort, 
exposure  to  the  sun's  rays,  venereal  excesses,  alcoholism,  etc.  The 
affection  is  more  common  in  men  than  in  women  (nine  to  four),  and 
occurs  at  all  ages,  but  especially  at  the  most  active  period  in  life — from 
puberty  to  fifty  years  of  age.  The  secondary  is  probably  the  only 
form  of  the  disease,  and  arises  from  injury  and  contusions  of  the 
head  ;  disease  of  the  nasal  fossae,  frontal  sinuses  and  orbit ;  caries  of 
the  cranial  bones,  and  especially  of  the  petrous  bone,  from  disease  of 
middle  ear.  Besides  traumatism,  the  most  frequent  cause  is  caries  of 
the  bones.  Rarely  encephalitis  has  occurred  in  the  course  of  acute 
infectious  diseases,  and  more  frequently  from  infective  emboli. 

Pathological  Anatomy. — The  points  of  inflammation  are  always 
circumscribed,  and  vary  in  size  from  an  almond  to  an  orange.  They 
may  be  multiple,  or  occupy  several  parts  at  the  same  time,  but  this  is 
not  usual,  and  when  so  the  individual  collections  are  small.  The  usual 
position  of  the  inflammation  is  in  the  corpora  striata,  optic  thalami,  the 
gray  matter  of  the  cortex,  the  cerebellum,  the  abscess  forming  in  the 
white  matter  of  the  hemispheres.  They  are  said  to  be  more  frequent  in 
the  left  than  in  the  right  hemisphere.  The  abscesses  may  or  may  not 
be,  but  usually  are  encysted,  or  inclosed  in  a  limiting  membrane.  They 
are  irregularly  circular  in  shape,  and  when  not  encysted  the  walls  of 
the  cavity  are  extremely  irregular^  masses  of  breaking-down  cerebral 
matter  projecting  into  the  pus,  which  is  also  diffused  into  the  surround- 
ing textures.  The  abscess  is  composed  of  rather  thick,  greenish,  odor- 
less, but  sometimes  fetid  pus  and  disintegrated  remains  of  the  cerebral 
tissue.  The  initial  change  at  the  site  of  the  abscess  is  hypersemia  ; 
minute  extravasations  take  place  (capillary  haemorrhages),  giving  to 
the  inflamed  area  a  dark,  reddish  color,  whence  the  term  red  softening  ; 
migration  of  white  corpuscles,  diapedesis  of  some  red  corpuscles,  and" 
exudation   of   serum  holding  albumen  and  fibrin  in   solution,   occur 


ABSCESS   OF   THE   BRAIN.  529 

simultaneously.  The  brain-tissue,  being  soft  and  easily  broken  up,  is 
rapidly  disassociated,  and  its  elements  disintegrated,  and  in  a  short 
time  a  soft,  pultaceous  red  mass  results,  which  more  and  more  assumes 
a  purulent  character,  becoming  first  reddish-yellow,  then  yellow  or 
greenish-yellow,  ultimately  almost  white.  The  limiting  membrane 
consists  of  a  connective-tissue  material  constructed  from  the  neuroglia. 
The  part  which  the  cells  of  the  neuroglia  and  the  cellular  elements  of 
the  gray  matter  (which  most  readily  takes  on  the  suppurative  inflam- 
mation) assume  in  the  process  is  not  definitely  known,  as  Rindfleisch 
frankly  admits.  The  encysted  abscess  may  take  either  of  two  direc- 
tions :  the  pus  may  be  gradually  absorbed,  the  cyst  undergoing  calci- 
fication, or,  after  a  quiescent  period,  set  up  a  new  disturbance,  ending 
in  death,  which  is  vastly  more  common.  When  the  abscess  approaches 
the  surface,  meningitis  is  excited  and  adhesions  of  the  membranes  may 
take  place  to  neighboring  parts  and  to  the  walls  of  the  abscess.  The 
injury  caused  by  an  abscess  is  not  limited  to  the  portion  of  brain  in- 
flamed, but  the  neighboring  territory  is  in  the  condition  of  collateral 
hyperaemia  and  cedema. 

Symptoms. — There  are  three  stages  in  the  course  of  encephalitis  : 
inflammatory  ;  period  of  silence  ;  coma.  Not  all  conform  to  this,  and 
hence  variations  must  receive  some  attention,  and  the  symptoms  are 
much  influenced  by  the  locality  of  the  lesions.  There  are  symptoms 
common  to  cerebral  abscess,  and  symptoms  only  produced  by  abscess 
in  certain  situations.  The  symptoms  of  the  inflammatory  stage  are 
headache,  vertigo,  noises  in  the  ears,  double  vision,  strabismus  (tempo- 
rary), sometimes  affections  of  speech,  numbness  and  tingling  in  certain 
members,  sudden  muscular  cramps,  incoordination  of  muscles  in  walk- 
ing, sometimes  nausea  and  vomiting  without  cause,  irritability  of  the 
bladder,  etc.  If  these  symj^toms  have  followed  a  blow  on  the  head,  or 
have  come  on  in  the  course  of  an  otoiThoea,  or  of  a  long-standing  affection 
of  the  nose,  attention  should  be  directed  to  the  probable  development 
of  an  encephalitis.  After  some  days  or  weeks  of  these  symptoms  an 
apoplectic  seizure  may  occur,  or  convulsions  of  an  epileptiform  charac- 
ter or  delirium.  Rigidity  and  contraction  of  one  side  or  of' both  sides 
are  found  to  exist,  succeeding  the  seizure,  the  period  of  unconsciousness 
being  short;  also  strabismus,  double  vision,  and  embarrassment  of  speech 
(amnesic  aphasia).  Sometimes  the  members  contracted,  sometimes  on 
the  other  side,  are  attacked  by  clonic  spasms,  and  occasionally  there 
are  general  convulsions  of  an  epileptiform  type.  The  intellect  is  not 
always  disturbed  at  the  beginning,  but  there  may  be  acute  maniacal 
delirium  or  simply  confusion  of  mind.  It  rarely  happens  that  paralysis 
— a  symptom  of  depression — appears  as  an  initial  symptom,  and,  if  so, 
it  may  be  safely  assumed  that  the  symptoms  of  irritation  escaped 
notice.  Heightened  general  sensibility — hypersesthesia — is  present  in 
the  parts,  the  seat  of  contractions  or  spasms,  but  anaesthesia  accom- 
34 


530    •  DISEASES   OF-  THE  NERVOUS  SYSTEM. 

panics  the  period  of  depression.  These  symptoms  of  the  inflammatory- 
stage  are  attended  by  fever,  not  of  a  special  type,  the  thermometer  ris- 
ing to  102°  or  103°  Fahr.  The  pulse  is  at  this  period  full  and  strong. 
The  urine  is  scanty  and  high-colored.  Nausea  and  vomiting  are  very 
persistent  symptoms  in  some  cases,  and  occur  to  a  greater  or  less  extent 
in  all,  and  this  statement  is  equally  true  of  constipation.  The  inflam- 
mation stage  proceeds  to  the  formation  of  pus,  and  includes  the  incap- 
sulation  of  the  abscess.  When  the  purulent  elements  are  diffusing 
through  and  disassociating  the  nervous  tissue,  the  symptoms  of  depres- 
sion succeed  to  excitation.  The  formation  of  pus  may  take  place  in 
five  or  six  days,  certainly  within  ten.  When  this  period  is  reached, 
mental  excitement  is  succeeded  by  somnolence  passing  into  stupor, 
contractions  and  rigidity  yield  to  relaxation  and  paralysis,  the  pulse 
becomes  slow,  the  respirations  shallow  and  irregular,  the  coma  deep- 
ens, all  reflex  movements  are  suspended,  and  death  ensues.  Excluding 
the  prodromic  period,  the  whole  course  of  the  disease  may  have  been 
completed  within  seven  to  ten  days.  Death  may  also  occur  in  these 
cases  in  the  apoplectic  coma,  in  the  convulsions,  or  in  the  acute  delirium 
which  marks  the  onset  of  the  inflammatory  period.  The  cases  do  not 
all  pursue  the  course  just  indicated.  When  the  stage  of  depression 
is  reached  there  may  be  a  period  of  improvement,  or  the  case  may  con- 
tinue with  the  hemiplegia,  the  local  paralysis,  at  a  fixed  point,  the  gen- 
eral condition,  however,  becoming  much  better.  If  the  abscess  is  so 
situated  in  the  hemispheres  as  not  to  involve  the  motor  or  sensory 
tracts,  the  symptoms  of  excitation  will  consist  of  delirium,  epilepti- 
form attacks,  etc.,  and  fever.  The  fever,  as  the  author  has  witnessed, 
and  verified  the  observation  by  post-mortem  examination,  may  be 
intermittent,  and,  although  somewhat  irregularly  so,  be  regarded  as  a 
genuine  intermittent,  and  treated  with  quinia.  The  period  of  silence 
is  rather  a  remission  than  a  complete  cessation  of  all  morbid  phenomena. 
As  already  indicated,  some  weakness  or  paralysis,  lowered  sensibility, 
defect  of  language,  or  impairment  of  mind  remains.  The  abscess  has 
been  inclosed  in  its  limiting  membrane,  and  cut  off  from  present  mis- 
chief. In  one  case  observed  by  the  author,  the  patient  so  far  improved 
in  condition  as  to  resume  his  occupation  after  a,  serious  illness,  but  he 
still  suffered  from  headache  and  vertigo  and  dimness  of  vision,  and  he 
experienced  a  remarkable  change  in  his  mental  state  :  having  been 
silent  and  reticent  before,  he  became  extremely  talkative  and  commu- 
nicative. This  fact  is  all  the  more  remarkable,  since  the  abscess  occu- 
pied the  right  anterior  lobe.  The  period  of  silence  is  of  variable  dura- 
tion, lasting  from  a  few  weeks  to  several  months,  during  which  the 
patient  may  be  cut  off  by  some  intercurrent  disease.  There  seems  to 
be  a  relation  between  abscess  of  the  right  hemisphere  and  pneumonia. 
This  period  may  be  suddenly  terminated  by  the  abscess  bursting  into 
the  ventricle,  or  at  the  surface  of  the  hemisphere,  which  will  be  an- 


ABSCESS  OF  THE  BRAIN.  53I 

nounced  by  violent  convulsions,  coma,  and  insensibility.  Usually  the 
end  of  this  period  is  announced  by  an  attack  of  intense  headache,  soon 
followecl  by  drowsiness,  and  terminating  in  coma,  or  by  convulsions 
and  coma,  or  more  slowly  by  a  new  meningitis.  Not  all  cases  of  en- 
cephalitis pursue  the  defined  course  just  described.  The  formation  of 
the  abscess  may  be  quite  latent,  and  no  symptoms  attract  attention  until 
convulsions  and  coma  announce  the  end.  Various  forms  are  described 
by  systematic  writers,  thus  :  the  meningeal  form,  in  which  the  fever 
is  high,  the  delirium  acute  ;  the  comatose  form.,  in  which  the  symp- 
toms of  excitation  have  been  latent,  and  the  early  development  of 
coma,  dilated  pupils,  convulsions,  and  muscular  resolution,  indicate 
the  extension  of  suppuration  and  early  death  ;  the  paralytic  form,  in 
■which  limited  abscesses  occur  in  the  motor  ganglia  at  the  base,  and 
paralytic  symptoms — hemiplegia,  aphasia,  and  ocular  disturbances — are 
present ;  the  apo]p'lectic  form,  in  which  sudden  unconsciousness,  fol- 
lowed by  rigidity  and  paralysis,  is  the  prominent  feature  ;  and  the 
epileptic  form,  characterized  by  the  predominance  of  eclampsia,  suc- 
ceeded by  paralytic  disorders. 

Course,  Duration,  and  Termination.— Notwithstanding  the  variabil- 
ity of  the  symptoms,  encephalitis  pursues  a  course  not  without  uniform- 
ity. From  the  reception  of  the  injury  until  the  development  of  active 
symptoms  is  the  prodromal  period,  of  uncertain  duration,  from  a  few 
days  to  several  weeks,  even  months.  When  the  inflammatory  process 
actually  begins,  the  duration  of  the  stage  is  about  a  week.  Death  may 
occur  at  this  period.  The  period  of  silence  is  very  variable  also,  and 
may  be  a  few  weeks'  to  several  months'  duration.  A  few  hours  or  a 
day  or  two  end  this  stage.  The  usual  termination  is  in  death.  Re- 
covery has  taken  place  during  the  stage  of  inflammation,  and  by  the 
discharge  of  pus  spontaneously  or  by  puncture. 

Diagnosis. — The  diagnosis  involves  the  question  of  the  seat  of  the 
abscess  and  the  differentiation  of  abscess  from  tumor,  from  cerebral 
hemorrhage,  and  from  meningitis.  If  the  abscess  is  situated  in  the 
hgemispheres  above  the  motor  ganglia,  there  will  be  delirium  and  con- 
vulsions, and  not  contractions  or  paralysis  ;  and,  if  in  the  region  sup- 
plied by  the  left  middle  cerebral  artery,  amnesic  aphasia  will  be  present. 
If  the  abscess  forms  in  the  motor  ganglia  at  the  base,  hemiplegia  will 
be  the  prominent  symptom  ;  or  paraplegia,  should  there  be  an  abscess 
on  both  sides.  If  the  abscess  forms  in  the  middle  fossa  of  the  skull, 
about  the  sella  turcica,  and  involves  the  crus  cerebri,  there  will  be 
paralysis  of  the  extremities  on  the  opposite  side,  and  of  the  third  nerve 
on  the  same  side.  If  the  abscess  occurs  in  the  neighborhood  of  the  pons, 
so  as  to  impinge  on  one  side,  there  will  be  a  crossed  paralysis  of  the 
facial  on  the  same  side  and  of  the  members  on  the  opposite  side.  Ab- 
scess of  the  cerebellum  gives  rise  to  incoordination  of  muscular  move- 
ments, vertigo,  vomiting,  amaurosis,  and  convulsions.     In  abscesses  of 


532  DISEASES   OF   THE   NERVOUS   SYSTEM. 

the  base,  the  cavernous  sinus  is  compressed,  and  hence  there  will  be 
present  swelling  of  the  eyelids,  injection  of  the  conjunctiva,  and  epis- 
taxis.  On  ophthalmoscopic  examination,  the  retinal  veins  are  swollen, 
tortuous,  and  the  disks  are  congested  and  stuffed  (choked  disks),  but, 
in  the  further  progress  of  the  cases,  white  atrophy  ultimately  results. 
In  abscess  of  the  base  and  cerebellum,  the  retinal  congestion  occurs 
earlier  and  is  more  pronounced.  There  is  no  symptom  of  tumor  which 
may  not  occur  in  abscess,  but  still  a  distinction  may  often  be  made. 
Tumor  develops  more  slowly  than  abscess,  and  is  unaccompanied  by 
fever.  The  symptoms  are  continuous  in  cases  of  tumor,  and  there  is 
no  period  of  silence.  Abscess  is  often  connected  with  injury,  with 
caries  of  the  bones,  disease  of  the  ear  and  nose  ;  tumor  develops  with- 
out any  cause.  Between  the  apoplectic  form  of  abscess  and  cerebral 
haemorrhage  there  is  no  well-marked  distinction  except  as  to  termination, 
which  resolves  the  doubts.  The  other  forms  of  abscess  do  not  come 
into  relation  to  cerebral  haemorrhage.  Abscess  of  the  cortex  and  menin- 
gitis present  the  same  symptoms  of  irritation  followed  by  depression, 
but  in  the  latter  there  is  no  period  of  silence  followed  by  relapse. 

Treatment. — The  stage  of  inflammation  requires  active  measures  to 
prevent  further  mischief,  as  the  remedies  already  advised  for  acute 
meningitis.  Ergot,  quinia,  and  chloride  of  barium  (liq.  barii  chloridi 
■rn,  XX  every  four  hours)  are  the  most  efficient  means  of  preventing  the 
migration  of  the  white  corpuscles  and  the  diapedesis  of  the  red.  When 
suppuration  occurs,  it  is  good  practice  to  check  the  formation  of  pus, 
and  the  collateral  oedema  and  hypersemia,  by  full  doses  of  quinia.  The 
propriety  of  trephining,  or  of  puncturing  the  brain,  to  favor  the  exit 
of  pus,  is  a  question  of  purely  surgical  interest,  into  the  discussion  of 
which  we  do  not  purpose  to  enter. 


INTRA-CRANIAL  TUMORS. 

Definition. — The  term  intra-cranial  tumor  is  a  more  correct  desig- 
nation than  cerebral  tumor,  for  it  includes  all  neoplasms  so  situated  as 
to  affect  the  contents  of  the  cranium.  The  term  cerebral  tumor  takes 
into  consideration,  if  restricted  to  its  proper  meaning  only,  tumors  of 
the  cerebrum,  and  not  those  of  the  meninges,  of  the  vessels,  etc.  By 
the  term  tumor  in  this  connection  are  intended  all  kinds  of  growths  or 
outgrowths,  and  it  is  not  confined  to  its  merely  technical  signification. 

Causes. — Intra-cranial  tumors  are  usually  divided  into  four  groups  : 
the  vascular  ;  the  parasitic  ;  the  diathetic  ;  and  the  accidental.  Tumors 
are  more  common  in  men  than  in  women,  simply  because  men  are 
more  exposed  to  the  influences  producing  them.  Injuries  excite  osseous 
and  connective-tissue  hyperplasia,  and  a  violent  strain  may  be  the 
cause  of  an  aneurism.  The  diathetic  tumors  are  in  part  transmitted 
by  inheritance,  in  part  acquired. 


INTRA-CRANIAL   TUMORS.  533 

Pathological  Anatomy. — Of  551  cases  of  aneurism  in  various  parts 
of  the  body,  only  seven  were  intra-cranial.*  The  arteries  of  the  base 
only  are  concerned,  for  a  miliary  aneurism  is  not  a  tumor  in  the  sense 
in  which  that  term  is  here  used.  The  internal  carotid  and  its  branches 
are  most  frequently  affected  ;  in  a  total  of  172  cases,  116  were  of  these 
vessels,  and  53  were  of  the  vertebro-basilar  arteries.  Taking  indi- 
vidual arteries,  we  find  that  in  a  collection  of  142  cases  there  were 
forty-one  of  aneurism  of  the  middle  cerebral,  forty  of  the  basilar, 
twenty-three  of  the  internal  carotid,  fourteen  of  the  anterior  cerebral, 
eight  of  the  posterior  communicating,  seven  of  the  vertebral,  four  of 
the  posterior  cerebral,  three  of  the  inferior  cerebellar,  and  two  of  the 
anterior  commimicating.  As  respects  the  side  of  the  brain,  the  left 
is  more  frequently  affected  by  aneurism.  In  a  collection  of  sixty 
cases,  thirty-five  were  on  the  left  and  twenty-five  on  the  right  side.f 
As  regards  size,  intra-cranial  aneurisms  vary  greatly,  those  of  the  an- 
tei'ior  and  middle  cerebral  artery  attaining  to  the  greatest  size.  From. 
a  pea  to  a  pigeon's-egg  is  the  usual  size,  but  they  may  attain  to  the 
dimensions  of  a  hen's-egg.  The  parasitic  tumors  consist  of  the  cysti- 
cercus  cellulosa?,  or  the  echinococcus.  The  former  are  small  vesicles 
the  size  of  a  pigeon's-egg,  composed  of  a  transparent  wall  and  pellucid 
contents.  They  are  found  often  in  large  numbers  in  the  gray  matter 
of  the  hemispheres,  in  the  pia  mater,  and,  as  the  author  has  seen,  on 
the  floor  of  the  fourth  ventricle.  The  echinococcus  cyst  is  larger,  often 
solitary,  and  never  exceeding  three  to  five.  It  has  a  tougher  investing 
membrane,  but  transparent  contents  in  which  can  be  seen  the  scolex 
with  its  booklets  (Davaine).  The  diathetic  tumors  are  cancer,  syphi- 
lis, and  tubercle.  Cancer  is  a  very  frequent  form  of  tumor,  and,  al- 
though at  one  time  was  supposed  never  to  occur  as  a  primary  disease, 
is  now  known  to  be  often  primary.  According  to  the  statistics  of  Le- 
bert,  of  forty-eight  cases  of  cerebral  cancer,  thirty-five  were  primary. 
According  to  Bacon,J  only  ten  in  seventy-three  cases  were  primary. 
Ogle  §  finds  that  thirteen  out  of  twenty-five  occurred  in  the  brain  alone. 
When  secondary,  there  are  several  nodules  ;  when  primary,  a  single 
one,  whici  is  usually  quite  separated  from  the  tissue  in  which  it  is  im- 
bedded. The  largest  tumors  are  those  growing  in  the  hemispheres, 
an  example  of  which  the  author  saw,  having  the  dimensions  of  the 
closed  fist.  The  form  is  usually  encephaloid,  rarely  scirrhous,  still  more 
rarely  colloid  and  melanoid.     The  position  of  the  cancer,  named  in 

*  "  Transactions  of  the  Pathological  Society,"  vol.  vii,  op.  cit. 

\  The  above  statistics  of  intra-cranial  aneurism  were  obtained  from  an  article  on  "An- 
eurism of  the  Brain  "  by  the  author,  published  in  the  "  American  Journal  of  the  Medical 
Sciences,"  October,  1872.  The  statistics  of  Lebert,  of  Durand,  and  of  Gougenheim,  were 
analyzed  in  this  article. 

X  "On  Primary  Cancer  of  the  Brain,"  London,  1865,  pamphlet. 

§  Reynolds's  "  System  of  Medicine,"  vol.  ii. 


534  DISEASES  OF  THE  NERVOUS  SYSTEM. 

the  order  of  relative  frequency,  is  the  hemispheres,  the  cerebellum, 
corpus  striatum,  optic  thalamus,  and  pons.  Cancer  of  the  orbit,  of  the 
scalp,  or  of  the  cranial  bones,  may  grow  inwardly  to  the  brain  ;  on  the 
other  hand,  cancer  of  the  brain  tends  to  develop  outwardly.  The 
form  of  syphilitic  tumor  is  a  gumma  of  the  dura,  and  may  occur  at 
the  convexity,  but  its  favorite  site  is  in  the  middle  fossa  of  the  skull, 
about  the  sella  turcica.  They  do  not  attain  to  great  dimensions,  rarely 
exceeding  a  walnut,  and  more  frequently  having  the  size,  as  also  the 
shape,  of  an  almond.  Tubercle-vudi&ses,  consist  of  an  aggregation  of 
cheesy  nodules,  and  vary  in  size  from  a  pea  to  a  walnut.  The  most 
frequent  situations  are  the  cerebellum  and  the  hemispheres,  and  much 
less  often  the  corpus  striatum  and  optic  thalamus.  The  group  of  intra- 
cranial tumors  called  accidental  contains  glioma,  sarcoma,  steatoma, 
myxoma,  psammomata  and  exostoses.  Gliomata  develop  from  the 
neuroglia,  and  are  hard  or  soft,  according  to  the  quantity  of  granular 
and  cellular  contents  and  fibrillse.  They  are  very  vascular,  and  hence 
may  be  accompanied  by  considerable  haemorrhage.  They  are  found 
in  the  hemispheres,  in  the  gray  and  white  matter,  and  may  be  attached 
to  the  membranes.  Of  the  sarcomata,  there  are  several  varieties  ;  they 
may  adhere  to  the  meninges,  or  develop  in  the  hemispheres,  or  in  the 
motor  ganglia,  at  the  base.  Lastly,  the  cholesteatoma,  which  grows 
from  the  arachnoid  or  pia  mater,  and  is  found  on  the  hemispheres  and 
in  the  posterior  fossa,  attains  by  the  aggregation  of  several  smaller 
tumors  sometimes  to  the  size  of  a  goose-egg.  A  growing  tumor  affects 
the  parts  in  its  immediate  neighborhood  by  the  irritation  which  its 
presence  excites,  and  by  destruction  of  tissue  effected  by  pressure. 
Neuritis  and  ultimate  softening  and  disintegration  of  nerves  impinged 
on,  inflammation,  absorption,  and  softening  of  the  adjacent  portion  of 
cerebral  matter,  are  pathological  results  of  the  proximity  of  a  tumor 
to  the  intra-cranial  organs.  Besides  the  local  effect,  a  growing  tumor 
increases  the  pressure  of  the  organs,  and  causes  a  displacement  of  the 
movable  contents  of  the  cavity,  the  blood  and  cerebro-spinal  fluid,  and 
an  approximation  of  the  perivascular  lymph-spaces.  Pressure  on  the 
sinuses  interferes  with  the  venous  circulation. 

Symptoms. — The  symptoms  produced  by  intra-cranial  tumors  are 
divisible  into  two  classes  :  those  common  to  tumors  in  all  situations  ; 
those  caused  only  by  tumors  in  particular  situations.  In  the  first 
group  are  headache,  vertigo,  amaurosis,  convulsions,  and  mental  dis- 
■  orders  ;  in  the  second,  aphasia,  strabismus,  ocular  paralyses,  and  hemi- 
opia,  tic-douloureux,  facial  spasm  or  paralysis,  deafness,  incoordination, 
vomiting,  crossed  paralyses,  etc.  Headache  is  of  so  persistent  and 
violent  character  that  Ladame*  holds  it  has  high  diagnostic  impor- 
tance. It  consists  of  paroxysms  of  acute  pain  and  a  constant  feel- 
ing of  uneasiness.      The  pain  is  increased  by  jarring  the  head,  by 

*  "  Symptomatologie  und  Diagnostik  der  Hirngeschwiilste,"  Wurzburg,  1865. 


INTRA-CRANIAL  TUMORS.  535 

tapping  even  gently,  and  by  a  full  inspiration.  Sometimes  the  posi- 
tion of  the  pain  indicates  the  site  of  the  neoplasm  ;  as  pain  in  the 
forehead,  when  the  tumor  is  in  the  anterior  lobe  ;  in  the  occiput, 
when  the  tumor  is  in  the  cerebellum.  Vertigo  comes  on  usually  some 
time  after  the  headache,  and  is  present  to  a  greater  or  less  extent  in 
all  cases,  but  is  more  pronounced  in  the  case  of  tumor  of  the  cere- 
bellum. Slight  fainting-fits,  with  or  without  the  most  transient  loss 
of  consciousness,  and  accompanied  by  intense  vertiginous  sensations, 
occur  in  many  cases.  Early  in  the  development  of  the  tumor  the 
vertigo  subsides  on  assuming  the  recumbent  posture  and  closing  the 
eyes,  but  later  the  vertigo  comes  on  severely  when  the  position  is 
horizontal,  the  bed  and  all  objects  being  in  more  or  less  rapid  mo- 
tion. In  advanced  cases,  the  vertigo  is  so  severe  as  to  prevent  walk- 
ing, or  at  least  to  render  it  difficult  and  uncertain.  Amblyopia  and 
amaurosis  are  also  symptoms  of  tumor  in  any  situation,  for,  as  Hugh- 
lings  Jackson  well  says,  "so  far  as  the  production  of  optic  neuritis 
by  intra-cranial  disease  is  concerned,  the  position  of  the  disease  seems 
to  be  of  little  consequence,  and  there  is  nothing  very  peculiar  in  its 
nature,  except  that  it  is  usually  coarse."  Graefe  held  that  the  retinal 
changes  were  due  to  direct  pressure  on  the  cavernous  sinus,  the  re- 
turn of  blood  from  the  orbit  being  thus  prevented,  but  Lancereaux 
and  others  demonstrated  that  the  pressure  was  not  sufficient  to  do 
this  in  the  case  of  many  tumors  situated  at  a  distance.  Neuro-reti- 
nitis,  then,  is  a  general  symptom  of  intra-cranial  tumor,  but  the  retinal 
and  orbital  changes  may  also  have  special  significance.  Convulsions, 
local  and  partial,  may  furnish  topographical  indications,  but  general 
convulsion  may  accompany  tumor  in  any  situation,  unless  we  except 
the  pons  Varolii,  on  the  dictum  of  Ladame.  Greater  or  less  depart- 
ure from  a  healthy  mental  state  is  observed  in  all  cases  of  tumor, 
and  those  involving  the  gray  matter  probably  affect  the  mind  more, 
but  actual  insanity  has  been  observed  in  about  one  third  only.  In 
many  cases,  changes  of  disposition  occur,  usually  in  the  way  of  morose- 
ness,  irritability,  and  depression  ;  in  others,  the  faculties  seem  enfee- 
bled, the  power  to  apply  the  mind  to  any  intellectual  effort  wanting  : 
but  the  author  has  seen  a  case  in  which  the  patient,  a  clerk,  developed 
a  great  capacity  for  the  acquisition  of  languages  during  the  time  when 
the  tumor,  which  occupied  the  posterior  lobe  of  the  left  hemisphere, 
was  forming.  Eccentricities  of  conduct,  delusions,  and  various  other 
forms  of  mental  derangement,  accompany  tumors  of  the  brain,  and  a 
considerable  proportion  of  such  cases  enter  asylums  for  the  insane. 
The  symptoms  which  serve  to  indicate  the  position  of  the  neoplasm 
are  very  important,  and  often  extremely  characteristic.  The  existence 
of  amnesic  aphasia — loss  of  the  memory  for  words — strongly  implies 
lesion  of  the  left  anterior  lobe,  fissure  of  Sylvius  or  island  of  Reil,  or 
of  the  parts  supplied  by  the  left  middle  cerebral.     A  tumor  of  the  cor- 


536  DISEASES  OF  THE  NERVOUS  SYSTEM. 

tex  of  either  liemisphere  may  give  rise  to  convulsive  movements  in  the 
hand  and  arm  of  the  opposite  side,  with  or  without  general  convulsions 
and  loss  of  consciousness,  and,  if  posterior,  will  involve  sensibility  as 
well  as  motility.  A  tumor  impinging  on  the  motor  centers  (corpus 
striatum,  thalamus  opticus,  etc.)  will  produce  first,  irritation — spasmodic 
contraction  and  rigidity  on  the  opposite  side,  and  next  depression  by 
destruction  of  tissue — paralysis  on  the  opposite  side  of  the  body.  A 
tumor  so  situated  as  to  impinge  on  the  crus  cerebri  and  the  third  nerve 
will  produce  symptoms  differing  according  to  the  injury  done  ;  if  the 
result  is  irritation,  irregular  movements  of  the  eye  (nystagmus)  on  the 
same  side,  and  rigidity  and  contraction  in  the  muscles  of  the  opposite 
side  of  the  body  ;  if  the  result  is  destruction  of  tissue,  there  will  be 
ptosis,  convergent  strabismus,  and  dilated  pupil  in  the  eye  of  the  same 
side,  and  paralysis  of  the  muscles  on  the  opposite  side  of  the  body. 
If  a  tumor  is  so  situated  as  to  compress  the  optic  nerve  at  the  outer 
side  of  the  chiasm,  the  field  of  vision  will  be  narrowed  to  a  degree  cor- 
responding to  the  extent  of  the  injury,  and  destruction  of  the  chiasm 
would  cause  blindness.  Irritation  of  the  olfactory  would  give  rise  to 
strange  smells,  and  destruction  of  the  nerve  to  loss  of  the  function. 
Tumors  at  the  base  may  involve  several  cranial  nerves,  causing  dis- 
turbances of  great  significance,  either  of  irritation  or  loss  of  function. 
If  the  fifth  nerve  is  irritated,  tic-douloureux  will  be  the  result ;  but,  if 
the  nerve  is  destroyed,  there  will  be  anassthesia  of  all  the  parts  to 
which  the  nerve  is  distributed.  A  tumor  of  the  pons  can  be  diagnos- 
ticated by  the  implication  of  the  fourth,  fifth,  and  sixth  nerves  on  the 
same  side,  and  by  disorders  of  motility  and  sensibility  on  the  opposite 
side,  and  by  the  absence  of  convulsions  (Ladame).  A  tumor  of  the 
medulla  oblongata  causes  disturbances  in  the  important  functions 
whose  centers  are  located  here — in  speech,  deglutition,  respiration — 
causes  disorders  of  sensibility  and  motility  on  the  opposite  side  and 
of  the  face  on  the  same  side  ;  causes  vomiting,  constipation,  and 
paralysis  of  the  bladder,  etc.  Tumors  of  the  corpora  quadrigemina 
affect  the  motions  of  the  eyes,  set  up  double  optic  neuritis,  and  cause 
paralysis  on  the  opposite  side  of  the  body.  Tumors  of  the  cere- 
bellum disorder  the  function  of  coordination,  especially  of  those  move- 
ments requiring  the  eyes  to  guide  them,  cause  excessive  vertigo, 
and  difficulty  in  maintaining  the  upright  position,  optic  neuritis  and 
early  extinction  of  vision,  and  general  convulsions.  Tumors  at  the 
base,  by  pressure  on  the  cavernous  sinus,  interfere  with  the  return 
of  blood  from  the  facial  vein,  and  cause  swelling  of  the  eyelids,  bleed- 
ing at  the  nose,  and  fullness  about  the  orbit.  A  growing  tumor, 
by  displacing  the  cerebro-spinal  fluid  through  the  internal  and  ex- 
ternal sheath  of  the  optic  nerve,  renders  the  eye  more  prominent, 
and,  by  pressure  on  the  cavernous  sinus,  maintains  congestion  of  the 
orbital  and  retinal  veins  ;  and  hence,  although  retinitis  occurs  when 


IXTRA-CRANIAL   TUMORS.  53Y 

tumors  are  in  the  hemisphere  anywhere,  it  will  develop  earlier  and 
more  severely  in  the  case  of  tumor  at  the  base.  It  has  been  ascer- 
tained that  considerable  atrophy  of  the  optic  disks  is  not  incompatible 
with  fairly  good  vision.  The  general  condition  of  the  subjects  of  in- 
tra-cranial  tumor  may  be  very  good.  When  there  is  vomiting,  there 
will  be  wasting  from  an  inability  to  retain  the  necessary  aliment.  If 
the  tumor  is  cancer,  the  peculiar  earthy  hue,  the  wasting,  and  emacia- 
tion will  soon  be  manifest. 

Course,  Duration,  and  Termination. — Obviously,  there  can  be  no 
uniformity  in  the  course  of  tumor.  The  symptoms  are,  at  first,  very 
indefinite,  and,  in  the  case  of  some  of  them,  at  least  months  are  occu- 
pied in  developing  any  well-defined  ailment.  A  persistent  headache, 
vertigo,  alterations  of  demeanor,  are  first  noticed,  and  gradually  the 
character  of  the  case  becomes  known.  Tumors  situated  in  parts  of  the 
brain  that  are  well  called  "  indifferent "  may  never  cause  characteristic 
symptoms,  but  usually  now  a  correct  diagnosis  may  be  made  if  the 
case  is  thoroughly  evolved.  The  duration  of  tumor  varies  from  two 
to  three  months,  cancer  five  or  more  years.  Unless  the  tumor  is  syphi- 
litic, or  possibly  aneurismal,  there  can  be  but  one  termination.  Some 
end  in  a  convulsion,  or  rather  in  the  secondary  coma  which  follows  it ; 
others  are  cut  off  by  an  intercurrent  disease,  and  notably  pneumonia, 
or  by  cerebral  haemorrhage,  or  by  acute  meningitis.  Aneurism  ter- 
minates by  rupture,  unless  by  treatment  its  consolidation  may  be  ef- 
fected. Before  the  access  of  the  final  coma  a  remarkable  degree  of 
somnolence  is  observed  in  some  cases,  sleep  continuing  for  several  days 
at  a  time  uninterruptedly. 

Diagnosis. — The  determination  of  the  position  of  the  tumor  has 
been  sufficiently  considered.  Can  a  diagnosis  be  made  of  its  nature  ? 
Aneurism  occurs  in  adults  or  the  old  ;  in  those  who  continue  to  have 
good  health,  and  who  are  not  affected  by  a  diathesis  or  an  hereditary 
ailment.  Vomiting  is  not  usual ;  the  cranial  nerves  are  early  para- 
lyzed, and  on  the  same  side  as  the  tumor  ;  the  mental  functions  are 
not  often  affected  ;  epileptiform  seizures  do  not  occur,  and  the  termi- 
nation is  by  an  apoplectic  attack.  An  aneurism  of  the  internal  ca- 
rotid within  the  carotid  canal  will  cause  protrusion  of  the  eye  by 
obstruction  of  the  cavernous  sinus,  and  may  be  accompanied  by  an  au- 
dible hruit.  A  tubercular  tumor  is  usually  accompanied  by  the  evi- 
dences of  tubercular  deposit  elsewhere.  The  subject  is  young,  and 
evidences  of  hereditary  taint  may  be  present ;  it  is  situated  deeply, 
often  in  the  indifferent  districts,  and  does  not  produce  disturbances  in 
the  cranial  nerves.  Syphilitic  gummata  have  a  tendency  to  form  in 
the  middle  fossa,  and  to  affect  the  cms  cerebri  and  third  nerve,  and 
are  usually  coincident  with  external  lesions.  Echinococci  or  cysti- 
cerei  are  accompanied  by  numerous  epileptic  attacks,  at  first  without 
any  injury,  but  subsequently  the  mind  becomes  torpid,  and  passes 


538  DISEASES   OP   THE  NERVOUS  SYSTEM. 

into  dementia.  Local  paralysis  and  hemiplegia  are  uncommon.  The 
distinctions  between  tumor  and  abscess  have  been  given  in  the  article 
on  abscess.  The  differentiation  between  obstruction  of  the  cerebral 
vessels  and  tumor  may  often  be  a  matter  of  extreme  difficulty.  Tu- 
mor may  appear  at  any  age ;  thrombosis  is  usually  a  disease  of 
advanced  life.  Thrombosis  is  accompanied  by  and  due  to  chronic 
arteritis  ;  tumor  is  not  related  to  general  arterial  changes.  Tumor  is 
characterized  by  intense  headache  ;  thrombosis  by  less  severe  and  per- 
sistent. Tumor  is  generally  accompanied  by  epileptiform  attacks  ; 
thrombosis  by  apoplectic.  Tumor  affects  the  cranial  nerves,  and 
causes  localized  paralysis  ;  thrombosis  never  produces  such  results. 

Treatment. — There  are  two  remedies  which  ought  always  to  be  used 
— iodide  of  potassium  and  ergot  ;  for,  although  only  syphilitic  and 
possibly  aneurismal  tumors  are  remediable,  the  case  under  treatment 
may  be  one  of  them.  Scruple-doses  of  the  iodide  of  potassium  should 
be  given  until  iodism  is  induced.  If  no  improvement  is  then  mani- 
fest, it  need  not  be  continued.  A  drachm  or  two  of  the  fluid  extract 
of  ergot  four  times  a  day  may  properly  be  given  for  several  weeks 
succeeding  the  iodide.  The  repetition  of  these  remedies  will  depend 
on  the  results  of  their  first  administration.  They  may  effect  a  cure  of 
the  syphilitic  and  vascular  neoplasms. 

APHASIA. 

Definition. — Inability  to  use  spoken  language  or  to  give  vocal  utter- 
ance to  ideas  is  designated  aphasia.  The  defect  may  consist  in  a  loss 
of  memory  of  the  words  by  which  ideas  are  expressed,  when  it  is  called 
amnesic  aphasia  ^  it  may  consist,  not  in  forgetfulness  of  the  words,  but 
in  an  inability  to  combine  the  different  parts  of  the  vocal  apparatus  for 
vocal  expression — ataxic  aphasia.  When  the  defect  involves  written 
language,  and  consists  in  an  inability  to  recognize  and  make  the  signs 
by  which  ideas  are  communicated  in  written  language,  it  is  named 
agraphia,  and  this  may  be  either  amnesic  or  ataxic — ^the  former  being 
a  mental  defect,  the  latter  an  affection  of  the  muscular  apparatus, 
known  as  writer's  cramp.  Amnesic  aphasia  exists  to  a  variable  extent, 
and  may,  indeed,  involve  but  a  limited  number  of  words.  Paraphasia 
is  a  term  proposed  by  Kussmaul  *  to  signify  the  mental  state  in  which 
the  wrong  words  are  used,  or  unintelligible  expressions  employed  to 
express  the  idea.  There  may  also  be  a  paragraphia — a  state  in 
which  wrong  or  meaningless  written  signs  may  be  used  to  expi'ess  the 
idea. 

Pathogeny. — Aphasia  and  its  various  modifications  are  associated 
with  a  number  of  intra-cranial  lesions  ;  with  occlusion,  either  by  throm- 
bosis or  embolism  of  the  vessels  ;  with  cerebral  haemorrhage  ;  with 
*  Ziemssen's  "  Cyclopaedia,"  op.  cit. 


APHASIA.  539 

encephalitis  and  abscess  ;  with  meningitis  ;  with  the  various  torms 
and  varieties  of  tumors  ;  and  it  may  be  a  merely  mental  and  moral 
condition.  Associated  with  so  many  and  varied  maladies,  and  occa- 
sionally existing  alone,  as  the  sole  evidence  of  disease  it  is  necessary  to 
give  the  subject  independent  and  separate  consideration.  We  can  not 
occupy  space  with  an  extended  historical  account  of  the  progress  in 
the  knowledge  of  this  peculiar  condition,  but  we  may  state  some  facts, 
and  begin  by  saying  that  to  Gall  unquestionably  belongs  the  credit  of 
first  suggesting  the  position  of  the  language  faculty.  He  says,  "  I  re- 
gard as  the  organ  of  verbal  memory  that  cerebral  part  which  rests  on 
the  posterior  half  of  the  roof  of  the  orbit."  *  Thomas  Hood,  quoted 
by  Hammond,!  so  long  ago  as  1822  described  accurately  a  case  of  apha- 
sia. Bouillaud  published  a  work  in  1825  to  prove  the  correctness  of 
Gall's  doctrines  that  the  language  faculty  was  situated  in  the  anterior 
lobes.  Marc  Dax  in  1836  made  the  remarkable  statement  that,  in  cases 
of  aphasia,  the  paralysis  was  on  the  right  side  and  the  lesion  on  the 
left,  thus  limiting  the  seat  of  the  language  faculty  to  the  left  frontal 
lobe.  The  next  and  most  important  step  was  that  taken  by  Br  oca  in 
1861,  who  sought  to  prove  by  cases  that  "the  integrity  of  the  third  left 
frontal  convolution,  and  perhaps  also  the  second,  is  essential  for  the  de- 
velopment of  the  power  of  articulate  speech."  The  observations  on  man 
seem  to  be  confirmed  by  the  experiments  of  Ferrier  J  and  Fritsch  and 
Hitzig,  which  show  that  electric  irritation  of  a  corresponding  part  in 
animals  is  followed  by  "  alternate  opening  and  closure  of  the  mouth, 
with  movements  of  the  tongue."  It  seems  to  be  now  pretty  definitely 
settled  that  lesions  of  the  region  supplied  by  the  left  middle  cerebral 
artery,  notably  the  island  of  Reil,  the  third  convolution,  and  the  neigh- 
boring part  of  the  corpus  striatum,  are  those  accompanied  by  the  va- 
rious forms  of  derangement  included  under  the  term  aphasia.  Hence 
it  is  that  right  hemiplegia  and  aphasia  are  so  often  associated.  First 
in  point  of  importance  are  lesions  of  Broca's  convolution,  next  those 
of  the  island.  Why  the  left  hemisphere  should  be  alone  the  seat 
of  such  a  faculty,  and  not  the  right,  has  received  various  explana- 
tions, but  that  offered  by  Broca  is  probably  the  most  nearly  true — that 
the  left  hemisphere  is  earlier  and  more  rapidly  developed,  receives 
more  blood,  and  is  therefore  first  and  chiefly  instructed,  whence  the 
greater  skill  and  education  of  the  right  hand.  Cases  of  left-handed 
persons  becoming  aphasic  from  disease  of  the  right  hemisphere  have 
been  reported.  There  are  cases  of  aphasia  in  which  the  power  to 
write  correctly  is  retained — aphasia  without  agraphia.  In  other  cases 
there  is  an  absolute  inability  to  communicate  ideas  by  written  signs, 
all  attempts  resulting  in  a  meaningless  scrawl.     The  two  functions 

*  Gall's  "Works,"  vol.  v,  p.  11,  translated  by  Winslow  Lewis,  M.  D. 
f  "Diseases  of  the  Nervous  System,"  op.  cit ,  p.  1*78,  sixth  edition, 
J  "Functions  of  the  Brain,"  American  edition,  1876,  p.  143. 


54:0  DISEASES   OF   THE  NERVOUS  SYSTEM. 

must  therefore  possess  different  centers  and  yet  be  in  close  proximity. 
Sign-speech,  or  the  power  to  express  ideas  by  signs,  or  sign-language, 
may  or  may  not  be  simultaneously  affected  with  the  language  faculty. 
As  patients  may  or  may  not  be  conscious  of  the  defect,  there  are  con- 
sequently an  amnesic  amimia  and  an  ataxic  ainimia.  As  amnesic 
aphasia  may  coexist  with  retention  of  the  power  of  written  language, 
by  which  the  intellect  may  be  tested,  it  has  been  demonstrated  that 
the  existence  of  aphasia  is  not  incompatible  with  the  full  possession  of 
the  intellect  in  all  other  respects.  A  number  of  cases  have  now  been 
reported  in  which  amnesic  aphasia  was  the  sole  lesion.  The  impor- 
tance of  this  observation,  from  the  medico-legal  point  of  view,  is  very 
great.  On  the  other  hand,  it  is  generally  true  that  the  mind  is  weak- 
ened or  impaired  in  other  respects,  so  that  the  presence  of  aphasia  is 
prima  facie  evidence  of  mental  impairment.  Aphasics  are  often  very 
curiously  damaged.  A  musician  could  not  read  the  musical  notes,  but 
could  play  by  ear  ;  on  the  other  hand,  Lasegue  saw  a  musician  with 
both  aphasia  and  agraphia,  who  could  write  down  notes  that  he  heard 
(Kussmaul)  ;  others  can  not  count  money,  or  distinguish  the  uses  of 
table-utensils. 

Course,  Duration,  and  Termination. — The  forms  of  aphasia  pursue 
a  course  parallel  to  the  malady  with  which  they  are  associated,  as  a 
rule,  but  sometimes  aphasia  ceases  before  the  disease,  or  continues 
after  the  disease  has  disappeared.  Aphasia  may  be  hysterical  or  due 
to  curable  disease,  as  syphilis,  or  it  may  be  produced  by  reflex  disturb- 
ance of  function,  as  parasites  in  the  intestines,  or  constipation.  The 
duration  will  be  brief  under  these  circumstances,  and  the  termination 
be  in  recovery,  if  right  means  are  used.  As  regards  the  influence  of 
permanent  lesions,  the  results  depend  somewhat  on  age,  for  in  chil- 
dren extensive  injuries  to  the  language  center  may  be  overcome  by 
training,  but  in  the  aged  limited  lesions  are  fixed  in  their  effects. 
Simple  amnesic  aphasia  is  more  favorable,  and  ataxic  aphasia  is  less 
favorable,  as  regards  the  prospect  of  recovery.  The  longer  the  con- 
dition of  aphasia  has  existed,  the  less  the  prospect  of  recovery.  The 
case  is  still  less  favorable  when  the  aphasic  state  is  increasing  pari 
passu  with  the  disease  on  which  it  depends. 

Treatment. — The  local  disease  must  be  removed  if  of  a  curable 
kind.  If  the  case  is  one  in  which  aphasia  persists  after  the  disease  on 
which  it  depended  has  been  removed,  much  may  be  done  by  suitable 
training.  An  admirable  example  of  the  results  which  can  be  obtained 
by  rightly  directed  effort  is  that  of  Bristowe,*  of  a  Canadian  in  St. 
Thomas's  Hospital,  perfectly  aphasic,  whose  speech  was  entirely  re- 
stored in  eight  months  by  a  course  of  carefully  conducted  speech-les- 

*  The  Lumleian  Lectures,  on  the  "  Pathological  Relations  of  Voice  and  Speech," 
London  "Lancet,"  June  21,  18Y9. 


H.EMORKHAGE   IN   THE   MEDULLA   OBLONGATA.  54I 

sons  given  by  Dr.  Bristowe.  These  Lumleian  lectures  deserve  the 
attentive  study  of  those  who  desire  to  have  a  truly  scientific  and  phil- 
osophical knowledge  of  the  subject. 


DISEASES  OF  THE  MEDULLA  OBLONGATA. 


HiEMORRHAGE. 

Pathogeny. — It  is  a  rare  event  to  have  haemorrhage  occur  in  the 
medulla  or  pons,  but  cases  have  been  reported.  The  conditions  caus- 
ing the  haemorrhage  are  doubtless  very  much  the  same  as  those  of  the 
brain,  miliary  aneurisms  and  atheroma  being  the  chief  factors.  The 
larger  aneurisms  of  the  basilar  artery  may  by  rupture  cause  a  haemor- 
rhage affecting  this  as  well  as  other  organs.  The  medulla  is  com- 
pressed by  haemorrhages  from  above,  breaking  through  on  to  the  floor 
of  the  fourth  ventricle.  These  conditions  are  not  now  under  consid- 
eration, the  inquiry  being  restricted  to  haemorrhage  into  the  pons  or 
medulla.  The  vessel  affected  in  any  case  is  small,  the  resulting  clot 
is  small,  but  there  are  usually  several  clots  at  the  same  time.  They 
vary  in  size  from  a  pea  to  an  olive,  but  those  examples  of  haemorrhage 
in  which  the  pons  is  simultaneously  affected,  or  which  occur  in  the 
pons,  are  much  larger.  One  case  is  reported  in  which  the  haemorrhage 
filled  the  whole  of  the  pons,  burst  through  on  the  left  side,  and  also 
filled  the  fourth  ventricle.*  Another,  in  which  the  pons  and  fourth 
ventricle  were  invaded,  and  into  the  right  crus  cerebii  there  was  also 
an  extravasation.! 

Symptoms. — If  the  haemorrhage  is  large,  vomiting  usually  occurs, 
consciousness  is  lost,  there  is  complete  muscular  resolution,  abolition  of 
all  reflex  acts  takes  place,  the  breathing  is  sighing  and  irregular,  be- 
coming rapidly  shallower,  or  is  stertorous  and  noisy,  the  pupils  are  apt 
to  be  irregular,  one  large  and  the  other  minutely  contracted,  or  both 
minutely  contracted,  death  occurring  in  an  hour  or  two,  or  in  a  day  or 
two,  in  a  deeply  comatose  state.  There  is  a  fulminant  fonn,  in  which, 
haemorrhage  taking  place  in  the  medulla  at  or  about  the  spasm-center, 
the  patient  falls  with  a  cry  into  general  convulsions,  becomes  comatose, 
and  dies  in  a  few  minutes,  or  in  an  hour  or  two.  ISTot  all  pursue  this 
rapidly  fatal  course.  A  small  clot  may  form  on  one  side  of  the  medul- 
la or  pons,  there  occur  the  usual  symptoms  of  apoplexy,  and  the  patient 

*  Dr.  T.  S.  Dowse,  "  Transactions  of  the  Pathological  Society,"  vol.  xxvii,  p.  7. 
f  Dr.  J.  W.  Ogle,  ibid.,  vol.  xv,  p.  9. 


542  DISEASES  OF  TEE  NERVOUS  SYSTEM. 

emerges  from  the  condition  of  unconsciousness,  after  some  hours  or 
days,  paralyzed  as  to  motion  and  sensation  on  the  opposite  side  (hemi- 
plegia), or  all  of  the  extremities  may  be  paralyzed  more  or  less  fully ; 
or  there  may  be  a  paraplegia,  the  arms  escaping,  but  usually  both  upper 
and  lower  extremities  are  affected  both  as  to  motility  and  sensibility. 
There  are  usually  paralyses  of  the  cranial  nerves — the  third,  fourth, 
fifth,  the  sixth,  the  seventh,  etc. — and  there  may  be  paralysis  of  the 
body,  on  the  opposite  side  of  a  unilateral  lesion,  while  the  cranial 
nerves  are  paralyzed  on  the  same  side.  The  breathing,  owing  to  the 
proximity  of  the  respiratory  center,  is  irregular  in  rhythm,  sighing, 
dyspnoBic — often  of  the  Cheyne-Stokes  type.  The  action  of  the  heart 
is  not  so  much  disturbed,  but  the  pulse  may  be  exceedingly  rapid  and 
irregular.  Epileptiform  convulsions  are  very  usual  and  important 
from  the  diagnostic  point  of  view,  since  Nothnagel's  "  spasm-center " 
is  located  in  this  organ,  and  hence  clonic  spasm  would  a  priori  be  ex- 
pected. Difficulty  in  swallowing  (dysphagia)  from  paralysis  of  the 
palatal  and  pharyngeal  muscles,  and  difficulty  of  speech  from  paraly- 
sis of  the  tongue  (ataxic  aphasia),  and  sometimes  an  obstinate  singul- 
tus, are  present  in  those  cases  emerging  from  the  first  coma.  Albu- 
men or  sugar  may  be  present  in  the  urine. 

Course,  Duration,  and  Termination. — As  the  facts  above  given  suf- 
ficiently indicate,  the  course  of  haemorrhage  into  the  pons  or  medulla 
is  rapid.  Death  may  occur  in  a  few  minutes,  in  a  few  hours,  or  after 
several  days.  Very  few  recover  in  the  damaged  way  above  described. 
If  such  partial  recovery  ensue,  the  usual  changes  of  an  atrophic  kind 
take  place  in  the  motor  tract  below  the  site  of  the  haemorrhage.  The 
paralyzed  muscles,  innervated  by  the  cranial  nerves,  it  is  probable, 
lose  their  electro-contractility  in  a  few  days. 

Diagnosis. — It  is  often  extremely  difficult  to  distinguish  between 
the  coma  and  insensibility  of  haemorrhage  into  the  pons  and  the  nar- 
cosis induced  by  opium  or  alcohol.  There  is  no  symptom  produced  by 
one  which  may  not  also  accompany  the  other,  but  the  antecedent  his- 
tory, taken  with  the  group  of  symptoms  as  a  whole,  ought  to  conduct 
to  right  conclusions.  The  deviation  of  the  head  and  eyes  to  the  side  of 
the  intra-cranial  disease,  and  from  the  paralyzed  side,  is  a  symptom  of 
cerebral  haemorrhage,  and  not  of  opium  or  alcohol  poisoning.  Con- 
vulsions are  uncommon  in  opium  and  alcohol  poisoning,  very  common 
in  haemorrhage  of  the  medulla.  The  pupils  ,are  often  contracted  in 
haemorrhage,  but  never  so  minutely  as  in  opium-poisoning.  During 
the  period  of  unconsciousness  it  may  not  be  possible  to  diagnosticate 
between  cerebral  haemorrhage  and  haemorrhage  of  the  pons  and  me- 
dulla, but  the  more  frequent  occurrence  of  convulsions,  the  vomiting, 
and  the  irregularity  of  respiration,  may  afford  indications.  Aftierward 
the  character  of  the  paralysis,  the  manner  in  which  the  cranial  nerves 
are  affected,  the  paralysis  of  the  palate,  and  difficulty  of  deglutition, 


ACUTE   BULBAR   PARALYSIS.  543 

the  singultus,  and  the  urinary  derangements,  serve  for  a  ready  and 
definite  decision. 

Treatment. — The  management  of  haemorrhage  into  the  medulla  or 
pons  is  the  same  as  for  cerehral  haemorrhage,  which  has  been  fully 
discussed. 

OCCLUSION  OF    THE  VESSELS   OF    THE   MEDULLA  AND  PONS 

VAROLH. 

Pathogeny  and  Symptoms. — The  vertebrals  and  the  basilar  are  the 
arteries  affected.  The  mode  of  occlusion  is  by  thrombosis  and  em^ 
holism,  and  the  pathological  results  are  such  as  have  been  described. 
The  immediate  effect  of  occlusion  of  the  vertebrals  is  a  sudden  and 
intense  anaemia,  with  or  without  loss  of  consciousness.  There  are  pa- 
ralysis of  the  tongue,  palate,  pharyngeal  and  laryngeal  muscles,  and 
paresis  of  the  facial.  Sometimes  the  ocular  muscles,  innervated  by  the 
third,  and  the  masseters  are  also  paralyzed,  and  usually  there  are  great 
irregularities  in  the  respiratory  and  cardiac  movements.  Paralysis  of 
the  four  extremities,  more  frequently  hemiplegia,  as  the  left  vertebral 
is  the  one  ordinarily  closed,  results,  and  there  may  be,  although  not  the 
rule,  lessened  sensation  in  the  same  parts.  Death  may  ensue  at  once  ; 
the  affected  area,  receiving  no  blood,  ceases  to  functionate.  In  other 
cases,  the  first  shock  of  the  accident  passes  off,  the  paretic  extremities 
contract  and  become  rigid,  and  may  remain  in  this  state  for  many 
years.  The  symptoms  produced  by  obstruction  of  the  basilar  are 
bilateral,  and,  as  the  glosso-pharyngeal  and  par  vagum  are  paralyzed, 
there  occur  at  the  same  time  severe  laryngeal  and  respiratory  symptoms, 
with  intense  dyspnoea,  and  rapid  carbonic-acid  poisoning,  and,  if  the 
immediate  effects  are  survived,  paralysis  of  the  four  extremities.  The 
treatment  of  this  malady  is  the  same  as  for  the  same  condition  affect- 
ing the  cerebral  vessels. 

ACUTE   INFLAMMATION   OF   THE   MEDULLA— ACUTE   BULBAR 

PARALYSIS. 

Pathogeny. — The  changes  resulting  from  inflammation  of  the  me- 
dulla oblongata  are  the  same  as  those  of  encephalitis  :  hyperaemia ; 
exudation  of  serum,  with  its  albumen  and  fibrin  ;  migration  of  white 
corpuscles  and  diapedesis  of  the  red  ;  disassociation  of  the  nerve-ele- 
ments ;  changes  in  the  neuroglia  (multiplication  of  its  cells) — the  ulti- 
mate result  being  a  spot  of  softening. 

Symptoms. — The  inflammation  makes  rapid  progress.  The  onset  of 
symptoms  is  sudden  :  a  violent  headache  ;  intense  vertigo  ;  nausea 
and  vomiting  ;  excessive  hiccough  ;  inability  or  great  difficulty  in 
swallowing  ;  toneless  voice,  or  speaking  difficult — and  these  symptoms 
appear  without  apoplectic  symptoms  or  convulsions.  As  the  medulla 
contains  so  many  important  centers  within  a  narrow  area,  it  is  obvious 


5^-4-  DISEASES   OF   THE   XERVOUS   SYSTEM. 

that  there  may  be  much  variety  in  the  symptoms.  If  the  pneumogas- 
tric  nucleus  is  inA^olved  there  will  be  emban-assed  breathing,  cyanosis, 
carbonic-acid  poisoning,  and  the  heart's  action  will  be  irregular,  rapid, 
and  weak.  Paralysis  usually  invades  the  extremities,  and  varies  much 
in  extent :  there  may  be  hemiplegia,  or  all  four  extremities  may  be 
weak ;  sensation  is  not  much  affected.  Neither  tonic  contractions  of 
the  muscles  nor  convulsions  have  been  observed.  The  progress  of  the 
case  is  rapid.  The  difficulty  of  swallowing  increases  to  absolute  inabil- 
ity ;  the  respiration  is  exceedingly  irregular,  and  carbonic  acid  accum- 
ulates so  that  coma  results,  death  occurring  by  failure  of  respiration. 

Diagnosis. — It  is  probable  that  many  cases  diagnosticated  hydro- 
phobia were  really  examples  of  this  disease.  The  distinction  between 
inflammation,  thrombosis,  and  embolism  of  the  medulla,  can  not  at 
present  be  made  with  certainty.  While  they  all  agree  in  symptoms 
of  derangement  of  the  important  centers  and  nerves  belonging  to  the 
medulla,  mj^elitis  of  this  part  is  not  accompanied  by  apoplectic  symp- 
toms or  convulsions,  which  belong  to  occlusion  of  the  vessels. 

Treatment. — The  treatment  is  the  same  as  that  suggested  for  en- 
cephalitis. 

CHRONIC   INFLAMMATION   OF  THE   MEDULLA— CHRONIC  PRO- 
GRESSIVE   BULBAR  PARALYSIS. 

Definition. — This  disease  is  probably  better  known  by  the  desig- 
nation given  it  by  Trousseau* — glosso-laMo- laryngeal  paralysis. 
This  tenn  was  intended  to  express  the  main  points  in  its  symptoma- 
tology. Other  names  proposed  are  :  progressive  rnuscxilar  paralysis 
of  the  tongue,  soft  pjaXaM,  and  lips  (Duchennef),  and  progressive 
atrophic  bulbar  ptaralysis  (LeydenJ).  Chronic  progressive  bulbar 
paralysis,  the  term  proposed  by  Wachsmuth,  and  adopted  by  Erb, 
well  expresses  the  seat  and  nature  of  the  disease. 

Causes. — The  origin  of  the  disease  is  very  obscure.  It  occurs  much 
more  frequently  in  men  than  in  women,  and  is  a  disease  of  advanced 
life,  rarely  occurring  before  forty.  It  has  been  referred  to  cold,  to 
shocks,  a  blow  on  the  neck,  to  rheumatism,  to  tertiary  syphilis,  to  deep 
chagrin  (Duchenne).  It  often  coexists  with  progressive  muscular 
atrophy  (Friedreich  §). 

Pathological  Anatomy. — Macroscopic  examination  may  furnish  only 
negative  results.  There  may  be  changes  of  color  and  a  dullness  of 
appearance  on  section,  and  the  medulla  as  a  whole  may  appear  to  be 
shrunken,  ||  or  harder  or  softer  than  natural,  in  places,  but  definite 

*  "  Clinique  Medicale,"  vol.  ii,  p.  274. 

f  "  D'Electrisation  localisee,"  second  edition,  p.  641. 

X  Quoted  by  Erb,  Ziemssen's  "  Cjelopsedia,"  vol.  xiii. 

§  "  Ueber,  progressive  Muskelatrophie,"  Berlin,  18Y3,  cap.  ix,  s.  322. 

li  Lockhart  Clarke,  "  Medico-Ghirurgical  Transactions,"  vol.  Ivi,  p.  103. 


BULBAR  PARALYSIS.  545 

results  are  obtained  only  by  microscopic  examination.  While  the 
lesions  in  the  medulla  are  so  obscure  to  the  naked  eye,  the  nerves  com- 
ing from  this  organ  are  changed  in  the  most  obvious  way,  especially 
the  hypoglossal  and  facial.  The  important  alteration,  in  regard  to 
which  observers  are  generally  agreed,  is  an  atrophy  and  degeneration 
of  the  multipolar  ganglion-cells  of  the  anterior  cornua.  The  vessels 
are  dilated,  leaving  vacuoles,  there  are  numerous  corpora  amylacea, 
the  cells  (nuclei  of  hypoglossus,  etc.)  are  crowded  with  pigment,  the 
neuroglia  overgrown  (hyperplasia).  Subsequently  the  cells  disintegrate 
and  disappear,  whence  the  marked  decrease  in  size.  The  nerve-roots 
and  the  nerve-trunks  are  also  much  changed,  the  nei've-fibers  having 
undergone  fatty  degeneration,  the  neurilemma  sclerosed,  and  the  axis 
cylinder  wasted  till  it  is  barely  visible,  and  only  a  mass  of  connective 
tissue  left.  The  most  advanced  changes  are  found  in  the  hypoglossal 
nucleus  ;  next,  the  spinal  accessory  and  the  par  vagum  are  attacked, 
and  the  facial  and  glossopharyngeal  are  more  or  less  damaged,  and, 
according  to  Clarke,  the  nucleus  of  the  fifth  is  invaded  to  some  extent. 
Similar  lesions  occur  in  the  brain  and  spinal  cord — throughout  the 
whole  extent  of  the  cord,  in  a  case  described  by  Lockhart  Clarke, 
which,  however,  was  accompanied  by  progressive  muscular  atrophy. 

Symptoms. — The  approach  of  the  disease  is  very  insidious.  Head- 
ache felt  in  the  occiput,  some  giddiness,  a  feeling  of  choking  in  at- 
tempting to  swallow,  a  sudden  inability  to  speak  (Cheadle),  are  the 
symptoms  first  observed.  The  voice  is  not  lost,  but  it  has  a  nasal  tone 
from  the  paralysis  of  the  palate,  and  there  is  great  indistinctness  in 
speech  because  of  the  loss  of  power  in  the  tongue  and  lips,  the  labial 
consonants  not  being  pronounced.  The  tongue  can  not  be  protruded, 
and  it  wastes,  becoming  soon  distinctly  smaller.  The  food  collects 
about  the  teeth  and  the  cheek,  so  that  the  fingers  are  needed  to  dis- 
lodge it.  The  saliva  dribbles  from  the  mouth,  the  lips  hanging  limp 
and  immovable.  The  taste  is  much  less  distinct  or  entirely  wanting. 
It  is  a  matter  of  great  difficulty  for  the  patient  to  get  the  alimentary 
bolus  back  into  the  pharynx.  The  efforts  at  swallowing  excite  cough- 
ing and  suffocative  attacks,  and  liquids  are  forced  back  through  the 
nose.  The  palate  and  pharynx  are  so  little  sensitive  that  no  reflex 
movements  are  caused  by  irritating  them.  The  soft  palate  hangs  limp 
and  motionless  in  the  fauces.  When  the  disease  reaches  this  point  the 
appearance  of  the  patient  is  eminently  characteristic  :  the  paralyzed 
lips  and  muscles  of  the  face  below  the  eye,  their  fibrillary  trembling, 
and  their  motionless  state  in  laughing,  the  flow  of  the  saliva,  the  fat- 
uous expression,  the  nasal  speech,  the  inability  to  sound  the  labials, 
the  choking  in  swallowing,  the  return  of  liquids  through  the  nose, 
form  a  striking  picture  which  no  one  can  fail  to  comprehend.  It  is 
the  sad  fate  of  these  patients  to  preserve  their  mental  faculties,  except 
that  they  become  somewhat  more  emotional  than  formerly,  and  to  con- 
35 


546  DISEASES   OF   THE  NERVOUS   SYSTEM. 

tinue  conscious  of  their  condition.  The  disease  is  truly  progressive — 
the  symptoms  already  described  grow  worse  in  every  way — speech 
becomes  less  and  less  intelligible,  swallowing  more  and  more  embar- 
rassing and  difficult,  and  the  saliva  increases  in  viscidity  and  quantity, 
the  patient  requiring  a  handkerchief  constantly  to  absorb  it.  Other 
and  more  formidable  symptoms  now  come  on.  The  extension  of  the 
disease  to  the  pneumogastric  nucleus  causes  a  paralysis  of  the  muscles 
of  the  pharynx,  the  voice  is  lost  after  preliminary  weakness  and  huski- 
ness,  the  respiratory  muscles  get  weak  and  the  hmgs  can  not  be  ex- 
panded, and  presently  there  are  experienced  oppression,  heaviness  of 
the  chest,  and  constant  dyspnoea,  with  paroxysms  of  a  suffocative 
character,  excited  by  the  presence  of  mucus  in  the  throat,  by  attempts 
of  sneezing,  coughing,  or  swallowing,  or  by  the  lodgment  of  some 
particle  of  food  in  the  larynx.  At  the  same  time  the  action  of  the 
heart  becomes  excited,  irregular,  and  weak,  and  attacks  of  praecordial 
oppression  with  a  sense  of  impending  dissolution.  The  condition  of 
the  patient  is  now  truly  pitiable.  The  mind  is  clear.  The  impossibility 
of  swallowing  leads  to  a  rapid  failure  of  strength,  and,  the  digestive 
organs  remaining  unimpaired,  an  intolerable  sense  of  hunger  is  felt. 
The  termination  may  now  be  in  a  sudden  failure  of  the  heart,  in  an 
attack  of  pneumonia  from  lodgment  of  a  foreign  body,  or  by  the  slower 
process  of  starvation.  The  sensibility  is  unimpaired.  The  faradic  con- 
tractility is  at  first  diminished,  but  the  muscles  soon  present  the  phe- 
nomena entitled  by  Erb  the  "  reaction  of  degeneration,"  If  the  mus- 
cles are  far  advanced  in  atrophy,  the  electro-contractility  may  be  lost. 
The  disease  in  the  medulla  is  often  associated  with  the  same  degenera- 
tion in  the  spinal  cord,  when  will  be  exhibited  the  phenomena  of  pro- 
gressive muscular  atrophy.  Paralyses  of  muscles  of  the  trunk  and 
extremities,  with  contractions  and  without  atrophy,  have  been  ob- 
served, but  these  are  probably  complications. 

Course,  Duration,  and  Termination, — The  course  of  the  disease  is 
progressive  ;  from  small  beginnings  it  grows  into  a  formidable  mal- 
ady. Sometimes  a  stay  in  the  progress  has-  been  noted,  but  only  for 
a  brief  period,  the  course  being  resumed  with  the  former  intensity. 
The  termination  is  fatal  in  from  one  to  five  years,  in  the  mode  above 
mentioned.  An  intercurrent  malady  may  fortunately  take  life  earlier  ; 
pneumonia  is  the  most  usual.  The  frequent  complication  of  progres- 
sive muscular  atrophy,  the  identity  of  the  muscular  condition,  and  of 
the  morbid  process  in  the  spinal  cord,  have  led  to  the  view,  now  gener- 
ally accepted,  that  the  diseases  are  the  same,  though  differing  as  to  the 
locality  in  the  spinal  cord  affected. 

Diagnosis. — Diseases  of  the  bulb  can  hardly  be  confounded  with 
those  of  other  localities,  because  of  the  peculiar  functional  disturb- 
ances which  indicate  at  once  the  seat  of  the  mischief.  Differentia- 
tion is  to  be  made  between  progressive  bulbar  paralysis  and  occlusion 


BULBAR  PARALYSIS.  547 

of  the  vessels,  acute  inflammation,  and  tumor.  Occlusion  of  the  ves- 
sels and  inflammation  occur  suddenly  with  very  severe  symptoms, 
often  apoplectic,  and  terminate  in  a  few  days.  Such  is  not  the 
behavior  of  progressive  bulbar  paralysis.  Tumor  of  the  medulla  and 
pons  comes  on  slowly  :  there  are,  at  first,  symptoms  of  irritation, 
followed  by  depression  ;  in  progressive  paralysis,  the  onset  is  slow  and 
obscure,  but  there  are  no  symptoms  of  irritation,  those  of  depression 
occurring  at  once.  In  the  case  of  tumor,  pressure  on  the  cavernous 
sinus  is  exhibited  in  swelling  of  the  retinal  veins  and  "  choked  disks," 
in  pufiiness  of  the  eyelids  and  distention  of  the  facial  vein — symptoms 
which  do  not  occur  in  bulbar  paralysis. 

Treatment. — Cheadle  *  reports  a  cure  by  the  free  administration  of 
iodide  of  potassium,  but  this  must  have  been  a  case  of  gummata.  Io- 
dide of  potassium  has  never  arrested  the  progress  of,  much  less  cured, 
a  genuine  case.  Galvanism  is  the  most  promising  remedy.  Stabile 
applications,  the  electrodes  on  the  mastoid  processes,  and  in  the  oppo- 
site direction,  galvanization  of  the  sympathetic,  and  applications  to 
the  lips,  tongue,  and  fauces,  should  be  persistently  used.  The  current 
should  have  sufiicient  tension  to  cause  slight  giddiness  and  faint  flashes 
of  light.  The  seances  should  be  short  but  daily,  and,  if  suspended  oc- 
casionally, can  be  kept  up  for  the  necessary  period.  Hydrotherapy  is, 
next  to  electricity,  the  most  useful  remedy.  A  wet  pack  can  be  worn 
about  the  neck  every  night,  and  a  hot  douche  may  be  directed  to  the 
nucha  for  five  minutes  daily,  but,  better,  a  sponge  dipped  in  hot  water 
and  kept  in  contact  with  the  back  of  the  neck  for  a  few  minutes. 
The  good  effects  of  the  water  applications  are  increased  by  the  daily 
use  of  a  mustard-plaster,  in  contact  long  enough  to  induce  a  little 
redness  and  nothing  more.  The  internal  medicines  have  not  effected 
any  improvement  in  the  cases  thus  far  treated.  As,  under  analogous 
conditions,  the  chloride  of  gold  has  been  of  great  service,  it  should  be 
given  a  fair  trial.  Bichloride  of  mercury  acts  similarly.  The  utility 
of  these  agents  probably  consists  in  their  power  to  check  the  over- 
production of  connective  tissue.  As  lead  and  other  metals,  slowly 
introduced  into  the  system,  will  produce  analogous  symptoms,  and  as 
syphilis  has  the  same  effect,  it  is  good  practice  in  every  case  of  pro- 
gressive bulbar  paralysis  to  give  iodide  of  potassium,  freely  at  first — 
its  subsequent  administration  being  governed  by  the  results  of  the  first 
trial.  From  the  beginning  the  utmost  attention  should  be  given  to 
the  diet,  so  as  to  postpone  the  period  of  decline.  Soft  solids  are  more 
easily  swallowed,  when  the  palate  is  paralyzed,  than  liquids.  Rectal 
alimentation  should  be  resorted  to  when  the  difficulty  of  swallowing 
becomes  great.  The  injection  of  defibrinated  blood  may  be  employed 
with  advantage. 

*  "St.  George's  Hospital  Reports,"  vol.  v,  p.  123. 


548  DISEASES  or  THE  XERVOUS  STSTEII. 


DISEASES    OF   THE    SPINAI.   MEis'INGES  AND 

CORD. 


HYPEILEMIA. 


Definition. — As  tbe  vascular  supply  to  the  meninges  and  cord  is  the 
same,  and  as  hyperemia  occurs,  necessarily  in  both  simultaneously, 
the  term  hypercmiia  must  be  understood  to  include  the  contents  of 
the  spinal  canal.  There  maybe  an  active,  or  arterial  hypergemia  ;  and 
passive,  or  venous  hypersemia. 

Causes. — Hypersemia  is  the  first  stage  in  the  inflammatory  affec- 
tions, and  is  a  notable  element  in  variola,  typhoid,  and  intermittent 
fever.  It  is  caused  by  over-stimulation  of  the  cord  in  the  performance 
of  its  functions  :  for  example,  protracted  standing  or  walking,  excesses 
in  coitus,  etc.  Certain  spinal  poisons  cause  hypersemia,  as  strychnia, 
picrotoxine,  amyl  nitrite,  and  alcoholic  excess.  The  arrest  of  such 
an  habitual  discharge,  as  from  bleeding  piles,  the  menses,  etc.,  diverts 
an  excessive  quantity  of  blood  to  the  cord.  Probably  the  most  fre- 
quent cause  is  exposure  of  the  body  while  in  a  heated  and  perspiring 
state  to  cold  and  dampness.  Congestion  is  produced  by  traumatism, 
concussion,  etc.  Workmen  engaged  at  labor  in  compressed  air  suffer 
from  hyjDersemia,  due  to  the  solution  and  setting  free  of  nitrogen  in 
the  blood  of  the  spinal  canal,  as  Bert  has  shown.  Venous  or  passive 
hypersemia  is  caused  by  obstructive  disease  of  the  heart  and  lungs,  by 
cirrhosis  of  the  liver,  and  by  tumors  of  the  abdomen. 

Pathological  Anatomy. — In  active  hypersemia,  vessels  come  into 
view  that  are  invisible  in  health,  and  those  of  larger  size  are  enlarged, 
giving  to  the  meninges  and  cord  a  distinctly  congested  appearance. 
On  section,  there  are  more  bloody  points  than  in  health  ;  and  numerous 
points  of  extravasation,  due  to  the  rupture  of  capillary  vessels,  are  to 
be  seen.  The  spinal  fluid  is  increased  in  amount,  and  is  more  or  less 
reddish  from  the  admixture  of  blood.  Passive  congestion  is  much 
more  distinct,  owing  to  the  large  size  and  numerous  anastomoses  of  the 
vessels,  which  are  greatly  distended,  more  or  less  tortuous,  and  cause 
a  bluish  discoloration  by  the  increase  in  size  of  the  numerous  small 
veins.  Ecchymoses  may  also  form  in  passive  congestion,  and  the  spi- 
nal fluid  is  somewhat  increased  in  quantity. 

Symptoms. — The  symptoms  are  of  two  kinds  ;  those  of  irritation 
and  those  of  depression.  The  onset  is  sudden  in  the  active  form,  some- 
what more  slow  in  the  passive  form.  Pain  in  the  back,  in  the  dorsal  or 
lumbar  region,  or  both,  radiates  downward  through  hips  and  thighs,  and 
is  increased  by  movements  and  by  percussion  of  the  skin.     The  pain 


HYPERiEMIA   OF   THE   SPINAL   CORD.  549 

is  rather  dull  and  heavy  than  acute.  Pains  are  felt  in  the  lower  limbs, 
often  of  an  acute  character,  and  with  the  pain  an  unpleasant  tingling. 
The  skin  of  the  lower  limbs  is  abnormally  sensitive,  and  the  reflex  ex- 
citability of  the  cord  is  somewhat  augmented.  A  slight  and  usually 
transient  sense  of  constriction  of  the  abdomen  is  felt,  and  the  abdomi- 
nal muscles  and  those  of  the  extremities  are  abnormally  tense  and 
rigid.  There  is  also  increased  tenderness  of  the  muscles  to  pressure, 
and  they  feel  sore  and  ache  a  good  deal,  even  when  at  rest.  The  elec- 
tro-contractility is  more  prompt  than  in  health.  These  symptoms  of 
irritation  occur  to  both  forms  of  congestion,  but  they  are  more  acute 
in  the  active  form.  The  symptoms  of  depression  immediately  succeed 
those  of  excitation.  Sensation  is  diminished  ;  the  lower  limbs  feel  be- 
numbed and  heavy,  and  the  movements  are  weak. 

Course,  Duration,  and  Termination. — The  symptoms  of  irritation 
exist  in  the  active  form  but  a  few  hours,  when  the  stage  of  depression 
comes  on,  the  two  groups  of  symptoms  intermingling.  The  whole 
duration  of  the  active  form  may  be  a  few  hours  to  two  or  three  days. 
The  cause  continuing  in  operation,  the  symptoms  will  continue  ;  but 
congestion  can  not  long  exist  in  the  active  form  without  setting  up 
myelitis.  The  stage  of  depression  coincides  with  the  escape  of  fluid 
from  the  vessels  and  the  occurrence  of  ecchymoses.  Then  the  cord 
and  the  nerve-trunks  being  impinged  on,  they  are  functionally  de- 
pressed. The  termination  is  in  recovery,  if  the  cause  is  removed,  or  in 
myelitis.  The  onset  of  the  passive  form  and  the  development  of  its 
symptoms  are  gradual ;  the  symptoms  are  not  so  pronounced  as  are 
those  of  the  active  form,  and  the  duration  is  only  limited  by  that  of 
the  cause  producing  it.  With  various  fluctuation  the  passive  form 
may  last  an  indefinite  period. 

Diagnosis. — Hypersemia  is  distinguished  from  the  more  severe 
affections  of  the  cord  by  the  mildness  and  transitory  chai-acter  of  the 
symptoms.  From  myelitis  it  is  differentiated  by  the  absence  of  fever, 
severe  pains,  contractions,  paralyses,  bed-sores  ;  from  meningitis,  by 
fever,  the  severe  symptoms  of  excitation  and  of  depression  ;  from 
spinal  haemorrhage,  by  the  suddenness  of  the  latter,  and  the  occur- 
rence of  depression  without  symptoms  of  excitation  ;  from  anaemia,  by 
the  symptoms  of  general  and  local  depression  characteristic  of  the 
latter. 

Treatment. — Lying  on  the  back  should  be  avoided.  Cups  or 
leeches  to  the  spine,  if  the  patient  is  plethoric,  should  be  applied.  If 
the  attack  has  succeeded  to  sudden  arrest  of  the  perspiration,  pilo- 
carpine should  be  used  to  reexcite  the  sweat.  If  the  congestion  is 
active,  the  spinal  ice-bag  may  be  applied.  The  blood-pressure  should 
be  reduced  by  an  active  purgative.  A  descending  stabile  galvanic 
current  should  be  used  once  daily  if  the  symptoms  persist.  A  hot 
douche  to  the  spine,  every  four  hours,  the  author  has  found  remark- 


550  DISEASES  OF  THE  NERVOUS  SYSTEM. 

ably  beneficial.  The  internal  remedies  most  useful  are,  for  the  active 
form,  tincture  of  aconite-root  (two  drops  every  two  hours),  and  infu- 
sion of  digitalis  (a  half -ounce  every  four  hours),  unless  the  symptoms 
of  depression  increase.  In  the  active  form,  the  author  has  had  excel- 
lent results  from  the  fluid  extract  of  gelsemium  (five  drops  every  four 
hours) ;  in  the  passive  form,  digitalis  and  ergot  (j — ^ij  3  fluid  extract 
of  ero^ot  every  four  hours)  are  the  most  efficient  means.  In  all  cases 
the  cause  must,  if  possible,  be  removed. 


SPINAL  MENINGEAL  HiEMORRHAGE. 

Pathogeny. — Injuries  and  diseases  of  the  vertebrse,  penetrating 
wounds,  rupture  of  a  vessel  from  strong  muscular  effort,  as  in  convul- 
sions, tetanus,  lifting  a  heavy  weight,  and  the  spontaneous  bleeding 
occurring  in  haemorrhagic  and  infectious  diseases,  as  hgemophilia,  scurvy, 
purpura,  variola,  typhoid,  etc.,  are  regarded  as  the  causes.  The  most 
frequent  position  of  the  haemorrhage  is  in  the  extra-meningeal  con- 
nective tissue.  It  may  form  a  clot  entirely  enveloping  the  dura,  or 
occur  at  isolated  spots,  or  extend  over  a  part  of  the  membrane.  The 
dura  itself  may  contain  numerous  ecchymoses.  The  coagulum  may 
also  coat  the  nerve-trunks  up  to  their  point  of  emergence.  In  the 
subarachnoid  space  there  may  be  a  quantity  of  blood,  partly  fluid 
and  partly  coagulated,  usually  quite  widely  distributed.  In  the 
meshes  of  the  pia  mater,  or  rather  in  the  subarachnoid  cellular  tissue, 
there  are  layers  of  dark  blood,  partly  fluid,  surrounding  the  cord,  and 
extending  longitudinally  the  distance  of  two  or  three  vertebrae.  The 
cord  will  be  compressed  if  the  hgemorrhage  is  large,  the  part  next  the 
blood  stained  red  and  softened  by  imbibition.  If  the  nerve-roots  are 
long  in  contact  with  blood-clot,  they  will  become  stained  and  soft- 
ened. The  spinal  fluid  will  be  red,  and  contain  particles  of  clot  float- 
ing in  it.  Hyperplasia  of  the  connective  tissue,  adhesions  between 
the  membranes,  and  extensive  pigment  deposits,  are  the  results  of  the 
final  changes  wrought  by  haemorrhage.  Spinal  haemorrhage  is  not 
unfrequently  associated  with,  or  rather  results  from,  cerebral  haemor- 
rhage, the  blood  flowing  down  into  the  spinal  canal. 

Symptoms. — The  usual  onset  is  sudden  :  intense  pains  in  the  back 
and  down  the  limbs  are  experienced,  and  the  patient  falls  powerless. 
The  other  and  much  less  common  mode  of  onset  is  slower  :  there  are 
pains,  strange  sensations,  headache,  and  gradual  failure  of  the  lower 
limbs.  In  rare  cases  cerebral  and  spinal  hemorrhage  occur  simul- 
taneously ;  there  are  then  sudden  loss  of  consciousness,  defects  of 
speech,  and  syncope,  in  addition  to  the  spinal  symptoms.  When  the 
immediate  effects  of  the  haemorrhage  subside — the  phenorhena  of 
shock,  or  apoplexy — then  are  seen  the  symptoms  of  excitation  due 
to  the  presence  of  the  blood.     Intense  pain  in  the  spine  about  the  site 


SPINAL   HEMORRHAGE.  551 

of  the  clot — the  whole  length,  one  division,  or  one  or  two  vertebrae  of 
the  spine — and  radiating  along  the  peripheral  tracks  of  the  nerves  im- 
pinged on  in  the  canal.  In  the  lower  extremities  will  be  felt  the 
referred  sensations  produced  by  pressure  on  the  cord — tingling,  burn- 
ing pain,  mixed  with  numbness.  Pressure  on  the  motor  nerves  pro- 
duces the  signs  of  irritation  in  the  muscles,  chiefly  contraction,  rigidity, 
and  cramp  ;  but  there  may  be  trembling,  local  convulsive  movements, 
etc.  The  muscles  of  the  spine  are  rigid,  and  motions  of  bending  or 
turning  the  body  are  painful.  The  symptoms  of  irritation  soon  yield 
to  those  of  depression.  Numbness,  formication,  diminished  tactile, 
and  painful  sensations,  succeed  to  the  pain  and  burning  ;  the  muscles 
become  Aveak,  and  a  sense  of  exhaustion  is  experienced.  Paresis  of 
the  bladder  and  rectum  is  observed  when  the  position  of  the  hasm- 
orrhage  is  low  down.  In  the  symptomatology  it  has  thus  far  been 
assumed  that  the  haemorrhage  was  not  higher  than  the  dorsal  region. 
Special  symptoms  are  produced  by  haemorrhage  in  the  cilio-spinal 
region,  and  the  more  if  high  enough  to  affect  the  origin  of  the  phrenic. 
The  occiput,  the  shoulders,  and  arms,  are  attacked  by  pain,  spasm,  and 
paralysis,  the  pupil  is  dilated  (irritation),  the  respiration  embarrassed 
(dyspnoea),  there  is  difficulty  in  swallowing,  and  the  pulse  is  slow  and 
weak. 

Course,  Duration,  and  Termination. — The  course  of  the  disease 
varies  with  the  site  and  extent  of  the  haemorrhage  and  the  compli- 
cations. The  first  stage  (apoplectic)  is  but  a  few  hours  in  duration, 
the  stage  of  irritation  a  few  days,  and  of  depression  two  or  three 
weeks.  If  the  haemorrhage  be  large,  cervical,  and  cranial,  death  may 
ensue  in  the  apoplectic  coma  ;  if  cervical,  death  may  be  caused  at 
once,  or  in  a  day  or  two,  by  the  disturbance  in  the  respiration  and 
heart.  Most  of  the  cases  in  the  dorsal  and  lumbar  part  get  well,  the 
clot  being  gradvially  absorbed.  During  the  stage  of  irritation  there  is 
more  or  less  reactive  inflammation,  and  the  products  of  this  help  to 
increase  the  after-depression.  The  whole  course  of  a  case  of  spinal 
haemorrhage  may  be  completed  in  one  or  two  months,  and  health 
restored  after  a  convalescence  requiring  two  months.  The  prognosis 
wall  be  influenced  by  the  violence  of  the  initial  symptoms,  by  the 
extent  of  the  haemorrhage,  the  number  and  severity  of  the  signs  of 
irritation,  and  by  the  extent  of  the  symptoms  of  depression. 

Diagnosis. — Spinal  haemorrhage  is  to  be  differentiated  from  hyper- 
semia,  spinal  meningitis,  haemorrhage  into  the  cord,  and  myelitis.  It 
is  distinguished  from  hypersemia  by  the  suddenness,  the  violence,  and 
the  range  of  the  symptoms  ;  from  meningitis  and  myelitis,  by  the 
absence  of  fever,  and  by  the  suddenness  of  onset  and  more  manage- 
able character  ;  from  haemorrhage  into  the  cord,  by  the  fact  that  in  the 
latter  there  are  sudden  paralysis  without  excitation,  and  extensive 
anaesthesia. 


552  DISEASES   OF   THE  NERVOUS   SYSTEM. 

Treatment. — Absolute  quiet,  the  decubitus  on  the  side  or  face,  are 
the  first  measures.  Severe  pain  must  be  combated  by  the  hypoder- 
matic injection  of  morphia,  which  is  furthermore  very  useful  to  remove 
restlessness.  If  the  haemorrhage  is  going  on,  ergotin  should  be  freely 
used  hypodermatically,  and  general  bleeding  practiced  if  the  subject 
is  plethoric.  Bloodletting  is  improper  if  the  haemorrhage  has  stopped. 
To  promote  absorption,  the  best  measures  are  purgatives,  infusion  of 
dio-italis,  and  the  occasional  administration  of  pilocarpine.  Good  results 
are  obtained  by  the  persistent  use  of  ammonia — ten  grains  of  the  car- 
bonate in  a  tablespoonful  of  the  liquor  ammonii  acetatis  three  times  a 
day.  The  products  of  inflammation  (reactive)  are  best  removed  by 
the  galvanic  current  to  the  spine  daily,  by  the  hot  spinal  douche,  and 
by  the  spinal  pack  worn  for  a  few  hours  at  a  time. 


INFLAMMATION  OF    THE    SPINAL   DURA  MATER— PACHYMEN- 
INGITIS SPINALIS— PACHYMENINGITIS   SPINALIS   INTERNA. 

Definition. — Inflammation  of  the  spinal  dura  mater  corresponds  to 
the  same  process  of  the  cerebral  dura  mater,  and  the  same  nomen- 
clature is  used.  Pachymeningitis  spinalis  means  inflammation  of  the 
spinal  dura  mater,  and  it  may  be  external  or  internal,  the  former  asso- 
ciated with  external  diseases  and  injuries — the  latter  arising  from  ordi- 
nary causes.  As  the  latter  possesses  the  greater  interest  and  impor- 
tance, it  is  alone  considered  here.  There  are  two  forms  of  pachymenin- 
gitis spinalis  interna  :  the  hypertrophic,  and  the  pseudo-membranous. 

Pathogeny  and  Symptoms. — Exposure  to  cold  and  dampness  com- 
bined and  living  in  damp  habitations  are  said  to  be  the  chief  causes  of 
the  variety  known  as  the  hypertrophic.  The  hsemorrhagic  form  is 
precisely  the  same  as  the  hsematoma  of  the  cerebral  dura  mater,  and  is 
usually  found  in  the  subjects  of  dementia  paralytica  and  of  alcoholic 
excess.  In  the  hypertrophic  form  a  great  quantity  of  exudation  is 
poured  out  on  the  inner  surface,  which  solidifies  into  a  compact  con- 
nective tissue,  arranged  in  concentric  layers.  This  ring  of  indurated 
tissue  more  or  less  tightly  embraces  the  cord  and  sets  up  a  secondary 
myelitis,  and,  equally  compressing  the  nerve-roots,  causes  them  to  un- 
dergo an  atrophy,  and  the  muscles  to  which  the  nerves  are  distributed 
also  waste  in  the  usual  way  of  muscular  atrophy.  In  the  hmmor- 
rhagic  form  a  membranous  exudation  also  takes  place,  developed  from 
the  sub-epithelial  layer  (Rindfleisch).  This  neo-membrane  is  abundant- 
ly supplied  with  large,  thin-walled  vessels,  which  yielding  a  large 
hoemorrhagic  extravasation,  in  the  interstices  of  the  membrane,  a  cyst 
is  thus  formed,  as  has  been  described  in  connection  with  cerebral 
pachymeningitis.  The  cewical  hypertrophic  pachymeningitis  is  one 
of  the  numerous  contributions  to  knowledge  made  by  Professor  Char- 
cot, who  has  shown  that  the  neck  is  a  favorite  seat  of  the  hypertro- 


SPINAL   MENINGITIS.  553 

phic  form.  lie  has  shown  that  the  first  stage  is  that  of  irritation,  and 
it  coincides  doubtless  with  the  stage  of  membranous  exudation.  This 
first  stage  is  characterized  by  violent  pains  in  the  head,  neck,  shoul- 
ders, and  arms^pains  that  are  continuous,  and  also  subject  to  exacer- 
bations— and  are  associated  with  a  painful  sense  of  constriction  around 
the  upper  thorax.  This  stage  of  irritation  continues  two  or  three 
months,  and  is  succeeded  by  depression.  Then  ensue  paralysis  with 
contraction  of  the  upper  limbs,  and  atrophic  degeneration  of  the  mus- 
cles, which  lose  their  electro-contractility  as  regards  the  f  aradic  cur- 
rent. Subsequently  the  lower  limbs  may  become  similarly  affected, 
but  to  a  much  less  extent.  After  remaining  stationary  for  a  long- 
time, a  change  for  the  better  may  take  place  and  a  cure  ultimately 
result. 

SPINAL   MENINGITIS— LEPTOMENINGITIS   SPINALIS. 

Definition. — When  the  term  spinal  ^neningitis  is  used  it  is  intended 
to  express  inflammation  of  the  arachnoid  and  pia  mater,  for  no  dis- 
tinction between  the  two  is  possible  either  in  respect  to  the  patho- 
logical or  clinical  standpoint.  There  may  be  an  acute  or  chronic 
form. 

Causes. — It  is  a  disease  of  the  male  sex,  and  occurs  in  youth  and 
adult  manhood.  All  depressing  influences  and  the  evils  of  bad  hy- 
giene tend  to  develop  it,  and  it  attacks  by  j^reference  the  subjects  of 
the  scrofulous  cachexia.  Exposure  to  cold  and  dampness,  while  the 
body  is  warm  and  perspiring,  is  an  influential  factor.  Penetrating 
wounds  and  injuries  and  diseases  of  the  vertebrae  have  a  dii-ect  effect 
which  is  unquestionable.  Neighboring  diseases  affect  the  spinal  me- 
ninges by  contiguity  ;  those  of  the  brain  have  the  most  immediate  con- 
nection. It  occurs  also  during  the  course  of  acute  infectious  diseases, 
as  puerperal  fever. 

Pathological  Anatomy. — After  an  intense  hyperemia  of  the  mem- 
branes, punctuated  by  ecchymoses,  much  fluid  is  exuded,  and  the  tissues 
are  swollen  and  infiltrated  with  serum.  A  quantity  of  exudation  partly 
purulent  and  pai'tly  fibrinous  is  poured  out  ;  the  spinal  fluid  becomes 
reddish  and  muddy  from  the  presence  of  cells,  flakes  of  fibrin  and  pus  ; 
the  membranes  are  infiltrated  with  pus-cells,  and  are  coated  more  or 
less  extensively  with  patches  of  fibrin,  the  whole  length  of  the  cord 
nearly  being  covered  with  exudation.  The  roots  of  the  spinal  nerves 
are  also  thickly  covered  with  exudation  and  bathed  with  a  pathologi- 
cal fluid — the  result  is,  they  are  swollen,  softened,  and  more  or  less 
injured  by  imbibition.  The  cord  itself  never  escapes  entirely  ;  it  may 
be  only  sodden  ;  it  may  be  softened,  congested,  and  oedematous.  In 
the  chronic  form  there  may  be  adhesions  of  the  membranes,  pigmen- 
tation, large  accumulation  of  fluid,  atrophic  and  sclerotic  degeneration 
of  the  coi'd,  etc. 


554:  DISEASES   OF   THE   NERYOUS   SYSTEM. 

Symptoms. — There  may  or  may  not  be  a  chill  to  mark  the  onset  of 
the  disease,  but  a  rise  of  temperature,  general  malaise,  headache,  nausea, 
and  constipation,  with  the  urine  acid  and  high-colored,  indicate  the 
beginning  of  an  inflammatory  affection.  Then  occur  the  local  pains, 
which  attract  attention  to  the  spine — pain,  of  a  severe,  deep,  bor- 
ing character,  in  the  loins,  back,  or  neck,  usually  in  the  dorso-lumbar 
region,  rigidity  of  the  spine,  a  constriction  or  girdle  of  severe  pain 
around  the  body,  and  pains  radiating  downward  into  the  limbs.  The 
motor  nerves  excited  by  the  exudation  cause  the  muscles  to  which 
they  are  distributed  to  assume  a  state  of  spasmodic  contraction,  limited 
to  the  lower  limbs,  to  the  rectum  and  bladder  (retention  of  urine  and 
constipation),  when  the  lesions  do  not  extend  above  the  last  dorsal  ; 
extending  to  the  muscles  of  the  trunk  and  the  superior  extremities,  to 
the  respiratory  and  posterior  cervical  muscles,  if  the  cervical  portion  of 
the  meninges  is  invaded.  When  this  portion  of  the  spinal  canal  is  oc- 
cupied by  the  inflammation,  there  occur  dysphagia,  dyspnoea,  slowing 
of  the  pulse,  and  feebleness  of  the  heart.  Striking  on  the  spinal  pro- 
cesses does  not  necessarily  awaken  pain,  but  much  soreness  is  felt 
when  the  spine  is  bent  in  the  movement  of  the  body.  It  is  important 
to  note  that  the  muscular  contractions  are  excited  and  increased  by  all 
attempts  at  movement,  whereas  irritation  of  the  skin  does  not  have 
this  effect — a  point  of  differentiation  between  meningitis  and  tetanus 
(Jaccoud).  With  this  condition  of  the  motor  functions,  there  are  also 
hypersesthesia  and  hyperalgesia  of  the  integument  in  the  area  of  motor 
derangement.  When  the  respiratory  muscles  are  affected,  at  this  stage 
death  occurs  early,  the  pulse  becomes  very  rapid,  the  dyspnoea  increases 
and  asphyxia  results.  Otherwise,  the  acute  symptoms  subside,  and 
the  remission  may  be  the  beginning  of  convalescence.  More  often  this 
diminution  of  the  acuity  of  the  symptoms  and  the  moderation  of  the 
excitation  denote  the  onset  of  the  paralytic — the  stage  of  depression. 
The  paraplegia  is  not  complete  ;  partial  contractions  remain  in  the 
paralyzed  members,  and  more  or  less  hypersesthesia  persists.  Consti- 
pation from  paresis  and  urinary  retention  are  replaced  by  inconti- 
nence, but  this  is  not  invariable.  Reflex  movements  are  not  abolished. 
Ansesthesia  will  more  or  less,  but  not  entirely,  replace  hyperaesthesia. 
The  electro-contractility  (faradic  current)  is  not  impaired  in  some 
muscles,  but  is  weakened  and  lost  in  others.  The  extensors  are  more 
often  affected  by  atrophy  and  loss  of  electro-contractility  (Rosenthal  *). 
The  cases  may  now  follow  two  courses  :  In  one  the  symptoms  of  paral- 
ysis will  invade  the  respiratory  muscles,  and  death  will  occur  in  coma 
(carbonic-acid  poisoning),  the  temperature  sometimes  rising  to  an 
extraordinary  height.  In  the  other  case,  the  course  will  be  more  pro- 
tracted ;  there  will  be  periods  of  apparent  improvement,  but  the  paraly- 

*  "  Klinik  der  Nervenkrankheiten,"  Stuttgart,  IS'ZS,  p.  286. 


SPIXAL   MEXIXGITIS.  555 

sis  will  extend,  bed-sores  will  form,  urine  will  dribble  away,  and  death 
occur  finally  by  exhaustion.  If  the  disease  extend  to  the  medulla, 
there  will  be  produced,  besides  the  disturbances  of  respiration  and 
of  the  heart  which  occur  when  the  cervical  meninges  are  inflamed, 
affections  of  speech,  vomiting,  ocular  derangements,  delirium,  etc. 
There  is  no  characteristic  thermal  line  ;  the  fever  is  high  at  the  outset, 
but  the  temperature  declines  during  the  stage  of  depression,  to  rise 
sometimes  to  an  extraordinary  height  during  the  death-agony.  The 
appetite  is  lost,  the  body  wastes  rapidly,  and  emaciation,  in  the  cases 
with  bed-sores  and  death  by  exhaustion,  proceeds  to  a  remarkable  ex- 
tent. The  chronic  form  of  spinal  tneningitis  succeeds  to  the  acute 
cases  of  moderate  severity,  or  originates  spontaneously — the  latter 
more  frequently.  It  presents  the  same  form  and  order  of  symptoms — 
those  of  excitation,  those  of  depression.  These  effects  are  due  to  effu- 
sions and  membranous  exudations  in  the  spinal  canal.  The  membranes 
are  thickened,  pigmented,  and  adherent  to  each  other  and  to  the  cord. 
The  pressure  of  the  contracting  sclerotic  connective  tissue  induces 
atrophy  of  the  nerve-roots,  and  if  the  posterior  roots  are  impinged  on 
degeneration  may  occur  in  the  posterior  columns  (Rosenthal).  The 
cord  itself  is  ultimately  damaged  by  a  parenchymatous  myelitis.  The 
symptoms  of  irritation  are  chiefly  expressed  in  disorders  of  sensibility, 
muscular  rigidity  and  spasm  being  partial  and  fugitive.  The  pain  is 
felt  in  the  lumbar  region  and  through  the  lower  limbs,  and  has  a  rheu- 
matismal  character.  The  pain  is  accompanied  by  hypersesthesia,  which, 
however,  is  never  so  considerable  as  in  the  acute  form.  Paraplegia 
develops  slowly  :  at  the  first  there  is  a  strong  sense  of  fatigue,  then  of 
increasing  weakness  ;  numbness,  tingling,  and  slowly  marching  plantar 
anaesthesia,  come  on  in  the  order  named.  The  weakness  extends  to  all 
the  muscles  of  the  inferior  extremity,  and  to  the  rectum  and  bladder, 
and  may  ultimately  invade  the  upper  extremities,  always  in  its  march 
attacking  the  two  sides  of  the  body  equally.  This  form  of  paraplegia 
is  irregular  in  its  progress — now  advancing,  now  receding. 

Course,  Duration,  and  Termination. — The  fulminant  form  termi- 
nates in  a  few  hours  or  a  few  days,  its  course  being  characterized  by 
the  extent  and  diffusion  of  the  symptoms,  the  early  implication  of  the 
cervical  portion,  and  consequent  failure  of  the  lungs  and  heart.  The 
ordinary  severe  form  lasts  two  or  three  weeks,  and  terminates  in  either 
of  two  modes  :  in  from  one  to  two  weeks  by  the  embarrassment  of 
respiration  and  weakness  of  the  heart,  coma  developing  in  consequence 
of  carbonic-acid  poisoning  ;  in  from  two  to  four  weeks,  by  gradual 
failure,  death  being  due  to  exhaustion.  The  severe  form  may  termi- 
nate in  recovery.  At  the  end  of  the  excitation  period  a  remission  in 
the  symptoms  occurs,  the  stage  of  depression  does  not  develop  into 
paraplegia,  and  convalescence  proceeds  slowly,  the  health  being  rees- 
tablished not  until  two  or  three  months  have  elapsed.     In  the  most 


556  DISEASES   OF   THE   NERVOUS   SYSTEM. 

favorable  cases  a  change  for  the  better  may  take  place  in  the  exci- 
tation period  in  a  few  days,  and  convalescence  be  established,  or  the 
symptoms  be  resumed  in  a  milder  form,  convalescence  being  then 
established.  Not  unfreqiiently  some  critical  evacuation,  such  as  a  pro- 
fuse sweat  or  urinary  discharge,  an  epistaxis,  or  menstrual  or  hsemor- 
rhoidal  discharge,  marks  the  cessation  of  the  morbid  process,  and  a 
rapid  recovery  then  takes  place.  More  frequently  the  recovery  is 
slow,  owing  to  extensive  exudations,  and  there  is  a  long  period  of 
lameness  or  paralysis.  Again,  recovery  may  ensue  with  permanent 
disability  of  a  member,  or  group  of  muscles.  In  any  case,  the  prog- 
nosis is  serious. 

Diagnosis. — The  distinction  between  tetanus  and  spinal  meningi- 
tis rests  on  these  points  :  trismus  is  among  the  first  symptoms  of  teta- 
nus, and  rarely  occurs,  and  then  later  in  spinal  meningitis  ;  risus  sar- 
donicus  is  peculiar  to  tetanus;  the  spasms  are  rhythmical  in  tetanus,  are 
more  severe,  and  are  excited  by  reflex  causes — similar  spasms  do  not 
occur  in  meningitis,  are  much  less  severe,  and  are  only  excited  by 
movements.  In  tetanus,  no  oculo-pupillary  phenomena,  no  changes  in 
the  cranial  nerves,  no  delirium,  no  fever — all  occur  in  meningitis.  The 
history  of  the  case,  especially  the  presence  of  a  wound,  will  often  de- 
cide. From  myelitis,  meningitis  is  differentiated  by  the  pain  in  the 
back,  the  hyperesthesia,  the  muscular  rigidity,  and  on  the  part  of 
myelitis  by  the  early  paraplegia  and  anaesthesia.  Rosenthal  places 
much  stress  on  the  electrical  state  of  the  muscles — the  electro-contrac- 
tility and  sensibility  (faradism)  of  the  nerves  are  much  lessened,  or 
disappear  entirely  in  spinal  meningitis.  From  typhoid  fever,  by  the 
thermal  line,  by  the  absence  of  the  irritation  symptoms,  by  the  diar- 
rhoea, by  the  stupor — in  fact,  the  least  attention  ought  to  decide 
promptly. 

Treatment. — Absolute  repose  in  a  darkened  room,  the  decubitus 
lateral  or  on  the  face,  must  be  insisted  on.  Leeches  or  cups  to  the 
spine  during  the  period  of  excitation — the  amount  of  blood  drawn 
being  dependent  on  the  vigor  of  the  subject.  The  application  of  the 
spinal  ice-bag  may  be  proper,  but  caution  is  necessary.  The  author 
has  a  strong  conviction  that  hai'dly  any  topical  application  is  to  be 
compared  with  the  hot  douche  to  the  spine,  or,  instead,  a  large  sponge 
dipped  in  hot  water  and  passed  frequently  over  the  spine.  The  most 
efficient  internal  medicines  are  opium,  aconite,  and  ergot — two  drops  of 
the  tincture  of  aconite-root,  five  to  ten  drops  of  the  tincture  of  opium 
(deodorized),  and  fifteen  to  thirty  minims  of  the  fluid  extract  of  ergot 
every  two  hours  during  the  stage  of  excitation.  If  the  pain  is  very 
severe,  the  hypodermatic  injection  of  morphia  may  be  necessary  at  the 
outset.  As  opium  is  a  remedy  of  the  greatest  importance,  its  effects 
should  be  steadily  maintained  during  the  excitation  stage.  When  the 
symptoms  of  depression  come  on,  quinia  (three  grains)  and  belladonna 


ACUTE   MYELITIS.  557 

extract,  (one  fourth  of  a  grain),  every  four  hours,  are  the  most  useful 
remedies.  The  paralysis  of  muscles  during  the  period  of  convalescence 
is  best  treated  by  faradization,  or  galvanism  slowly  interrupted,  if  the 
former  fails  to  induce  responses.  The  galvanic  current  should  be  ap- 
plied to  the  spine  and  to  the  nerve-trunks.  After  the  acute  symptoms 
have  subsided,  strychnia  may  be  injected  into  the  paralyzed  muscles. 
Massage  to  the  paralyzed  members  or  muscular  groups  is  an  expedient 
of  great  utility.  During  the  excitation  period,  and  after  cups  or  leeches 
have  been  applied,  mustard-plasters  to  produce  slight  rubefaction  are 
highly  useful.  Twice  a  day,  a  mustard-plaster  four  inches  broad  should 
be  put  on  from  the  occiput  to  the  sacrum,  and  removed  as  soon  as 
slight  redness  is  caused.  During  the  stage  of  depression,  ^y/?i^-blis- 
ters  to  the  spine  are  highly  serviceable.  Great  circumspection  is  ne- 
cessary, since  all  severe  counter-irritation  may  help  to  form  bed-sores. 
To  remove  deposits  from  the  spinal  canal,  especially  in  the  treatment 
of  the  chronic  form  of  spinal  meningitis,  and  the  pachymeningitis  in- 
terna of  the  cervical  region,  there  is  no  remedy  so  efficient  as  the  iodide 
of  potassium.     Full  doses  must  be  given. 

ACUTE    MYELITIS. 

Definition. — By  the  term  acute  myelitis  is  meant  an  acute  inflam- 
mation of  all  the  tissues  of  the  spinal  cord.  It  is  sometimes  subdi- 
vided into  parenchymatous  and  interstitial  myelitis,  but  as  regards 
the  acute  form  such  an  arrangement  is  not  at  present  made  with 
certainty. 

Causes. — Myelitis  is  more  common  in  males  than  in  females  ;  in 
youth  and  early  manhood  than  in  advanced  life.  One  form  occurs  in 
childhood.  Contusions,  blows,  fractures  of  the  vertebra,  severe  and 
prolonged  functional  activity  of  the  cord,  as  in  protracted  standing,  ex- 
cesses in  coitus,  self-abuse,  exposure  to  cold  and  dampness,  combined, 
are  the  most  common  causes.  Inflammation  of  the  cord  may  be  excited 
by  neighboring  inflammations,  transmitted  by  contiguity  ;  meningitis, 
traumatic  inflammation  of  the  dura,  and  carcinoma,  are  the  representa- 
tives of  this  group  of  causes.  It  is  one  of  the  complications  of  typhus, 
the  exanthemata,  puerperal  fever,  and  acute  rheumatism.  The  so- 
called  reflex  paraplegias  are,  probably,  examples  of  myelitis. 

Pathological  Anatomy. — The  first  step  in  the  process  is  hypergemia, 
which  is  usually  very  intense,  the  affected  area  being  deeply  red.  Ex- 
travasations also  occur,  and  hence  the  tissues  may  have  a  reddish-brown 
or  chocolate  tint.  With  the  hyperaemia  occur  serous  transudations, 
so  that  the  inflamed  district  is  moist  and  juicy,  and  softened.  A  change 
in  coloration  next  takes  place  to  yellow,  and  ultimately  to  white,  the 
nerve-elements  are  disassociated,  become  fatty,  and  finally  an  emulsioned 
mass  remains,  of  creamy  appearance  and  consistence.    The  meninges  of 


558  DISEASES   OF  THE   NERVOUS   SYSTEM. 

this  part  of  the  cord  take  part  in  the  inflammation,  become  thickened, 
opaque,  and  infiltrated  with  pus-cells,  and  contract  adhesions.  Such 
are  the  macroscopic  or  naked-eye  appearances.  On  microscopic  ex- 
amination the  changes  consist  in  dilatation  of  the  capillaries,  arteri- 
oles, and  veins  ;  in  the  migration  of  the  white  and  diapedesis  of  the 
red  corpuscles  ;  in  fatty  and  granular  infiltration  of  the  walls  of  the 
vessels  ;  in  the  exudation  of  a  colloidal  hyaline  substance  about  the 
vessels  ;  in  swelling  and  proliferation  of  the  neuroglia-cells,  and  a 
hyperplasia  of  the  reticulum  ;  in  the  exudation  in  great  numbers  of 
granule-cells  in  the  interstices  ;  in  the  granular  disintegration  of  the 
nerve-fibers,  the  axis-cylinders  forming  ampullary  dilatations  :  and  in 
swelling,  proliferation  and  granular  atrophy  of  the  ganglion-cells.  The 
continued  development  of  these  morbid  processes  results  in  the  almost 
entire  disappearance  of  the  proper  elements,  the  remaining  mass  being 
composed  of  fat-granules,  hypertrophied  neuroglia,  dilated  and  thick- 
ened vessels.  Cysts  are  sometimes  seen,  composed  of  a  dense  connec- 
tive-tissue envelope,  and  a  reticulum  of  the  same,  containing  serum 
and  detritus.  Without  proceeding  so  far  as  the  complete  destruction 
of  the  nerve-elements  (cells  and  fibers),  which  is  the  ultimate  step  in 
the  acute  process,  a  transition  to  the  chronic  forms  is  effected,  in  which 
there  is  an  hyperplasia  of  the  neuroglia,  the  spider-cells  enlarge  and 
increase  in  number,  the  vessels  undergo  thickening,  numerous  amyla- 
ceous corpuscles  or  bodies  appear,  while  the  nerve-elements  atrophy. 
The  central  gray  matter  is  the  chief  seat  of  this  disease,  but  it  extends 
so  as  to  involve  all  parts.  It  may  be  most  severe  in  the  gray  matter  ; 
it  may  have  an  haemorrhagic  character,  and  it  may  consist  chiefly  in  a 
hyperplasia  of  the  neuroglia. 

Symptoms. — The  usual  course  is  the  onset  by  a  chill,  fever,  and 
general  malaise.  Or  the  spinal  symptoms  begin  without  any  prelimi- 
nary. There  are  experienced  intense  pain  in  the  back,  with  a  band 
of  pain  and  constriction  around  the  body,  soreness  developed  by  per- 
cussion of  the  spine,  pains  and  muscular  soreness  of  the  limbs,  tingling, 
formication,  a  feeling  of  weight  and  dragging  in  the  rectum  and  blad- 
der, and  priapism.  There  may  be,  but  not  invariably,  corresponding 
symptoms  of  irritation  in  the  motor  sphere,  such  as  tremors,  spasmodic 
contractions,  clonic  convulsions  partial,  even  general.  But  paralytic 
symptoms  appear  in  a  few  hours,  and  soon  complete  paralysis,  and  dis- 
appearance of  the  electro-contractility.  Paralysis  of  the  sensory  nerves 
also  takes  place  in  a  short  time,  and  sensation  is  lost  more  or  less  com- 
pletely in  all  the  affected  region  up  to  the  upper  line,  often  terminat- 
ing quite  abruptly  about  the  middle  of  the  body.  Paralysis  of  the 
sphincters  may  follow  very  soon  (the  paralysis  of  the  muscles),  but  it 
may  be  delayed  for  some  time,  and  in  other  cases  it  may  not  occur  at 
all.  The  condition  of  the  reflex  function  varies  greatly.  All  reflex 
activity  may  be  abolished  ;  it  may  be  diminished  ;  it  may  be  un- 


ACUTE   MYELITIS.  559 

changed  ;  it  may  be  greatly  exaggerated — the  variations  being  due  to 
the  position  and  extent  of  the  lesion  in  the  cord.  Sometimes  the  pa- 
ralysis reaches  its  highest  at  once  and  is  afterward  stationary ;  some- 
times its  ascends  the  cord  and  rapidly  involves  the  parts  above  ;  some- 
times the  extension  is  transversely,  all  parts  of  the  cord  in  turn  being 
affected.  "When  the  inflammation  extends  horizontally  and  affects 
the  anterior  cornua,  the  paralyzed  muscles  waste  rapidly,  and  bed-sores 
form  quickly  and  spread  widely.  These  trophic  lesions  also  excite 
disease  of  the  mucous  membrane  of  the  genito-urinary  tract,  the  urine 
becomes  alkaline,  and  a  violent  and  destructive  pyelonephritis  and  cys- 
titis are  set  up,  the  paralyzed  limbs  become  (Edematous,  and  effusion 
takes  place  into  the  joints.  If  the  myelitis  is  of  the  ascending  variety, 
when  the  cilio-spinal  region  is  reached,  pupillary  phenomena  are  ob- 
served— enlarged  pupil,  if  the  sympathetic  centers  are  merely  irritated  ; 
contracted  pupil,  if  these  centers  are  destroyed.  "When  the  cervical 
portion  of  the  cord  is  reached,  the  muscles  of  respiration  becoming  par- 
alyzed— the  intercostals  and  trunk-muscles — breathing  can  be  carried 
on  only  with  the  diaphragm,  and  finally,  this  muscle  being  paralyzed, 
there  are  most  intense  dyspnoea,  rapid  filling  of  the  lungs,  and  death. 
The  fever  with  which  many  cases  are  inaugurated  pursues  no  defined 
plan.  In  some  cases  fever  persists  throughout,  in  many  it  is  parox- 
ysmal, but  without  regularity,  in  others  it  does  not  appear  at  all.  In 
some  instances  intense  fever  precedes  death,  and  is  higher  than  ever  for 
a  short  time  after  death.  The  pulse  is  frequent  usually,  very  frequent 
and  irregular  when  the  cervical  portion  of  the  cord  is  invaded.  The 
nutrition  in  some  cases  fails  rapidly,  in  others  is  preserved  fairly  well. 
There  is  obstinate  constipation  produced  by  paralysis  of  the  muscular 
layer  of  the  bowel,  and  meteorism  from  the  same  cause. 

CourSB,  Duration,  and  Termination. — There  are  numerous  variations 
in  the  course  of  the  disease,  due  to  the  position  and  tendency  of  the 
lesions.  If  the  paralysis  is  of  the  ascending  variety,  the  respiratory 
muscles  soon  become  involved,  and  death  takes  place  in  a  few  days  by 
asphyxia.  In  other  cases,  the  trophic  center  being  invaded,  there 
occur  extensive  bed-sores,  intense  pylonephritis  and  cystitis,  changes 
in  the  joints,  and  death  by  exhaustion  in  three  or  four  weeks,  or  as 
many  months.  It  occasionally  happens  that  the  morbid  process  is 
arrested  at  a  certain  stage,  and  the  health  is  restored  ;  but,  permanent 
damage  having  been  inflicted,  permanent  deformity  remains,  such  as 
wasted  and  paralyzed  muscles,  contractions,  and  deformities  of  joints. 
In  still  other  cases,  the  acute  passes  into  the  chronic  form  of  the  dis- 
ease. Rarely,  complete  recovery  ensues.  When  this  result  takes 
place,  a  remission  occurs  at  an  early  period,  the  pai'alysis  is  not  com- 
plete, and  slow  absorption  of  exudations  is  effected.  The  myelitis 
from  traumatic  causes  is  usually  situated  above  the  dorso-lumbar  en- 
largement, and  is  of  the  variety  known  as  myelitis  transversa.     The 


560  DISEASES   OF   THE   NERVOUS   SYSTEM. 

symptoms  present  are  the  constricting  band  around  the  body,  spinal 
pain,  paraplegia,  anaesthesia,  no  atrophy  of  the  muscles,  paralysis  of 
the  bladder,  and  reflex  contraction  of  the  muscles  more  active  than  nor- 
mal. The  electro-contractility  of  the  leg-muscles  is  preserved.  Cen- 
tral myelitis  affects  the  gray  matter,  including  the  anterior  horn.  This 
form  begins  abruptly,  proceeds  rapidly,  and  involves  sensation  and  mo- 
tion and  the  trophic  functions.  The  reflex  excitability  and  the  elec- 
tro-contractility (faradism)  are  quickly  extinguished,  the  muscles  waste 
rapidly,  the  muscles  of  respiration  are  quickly  paralyzed  by  extension 
upward  of  the  disease,  and  death  occurs  early  by  asphyxia.  The 
hseraorrhagic  form  differs  from  the  purely  central  myelitis  by  the  still 
more  abrupt  appearance  of  the  paralysis. 

Diagnosis. — Myelitis  may  be  readily  confounded  with  meningitis  ; 
they  differ  especially  in  respect  to  the  stage  of  irritation,  which  is  pro- 
nounced in  meningitis,  but  hardly  recognizable  in  myelitis.  In  menin- 
gitis, there  are  rigidity,  sj^asms  and  contractions  of  muscles,  pain  and 
hypersesthesia  ;  in  myelitis,  paralysis  appears  in  a  short  time,  involves 
the  rectum  and  bladder,  and  angesthesia  follows.  The  electro-contrac- 
tility is  preserved  in  meningitis,  but  often  lost  in  myelitis.  Hgemor- 
rhage  in  the  spinal  canal  is  distinguished  by  its  abruptness,  the  ii'rita- 
tive  symptoms  (absent  in  myelitis),  the  slight  paralysis  and  preserva- 
tion of  electro-contractility,  as  against  the  severe  paralysis,  wasting 
of  muscles,  loss  of  reflex  and  electric  excitability,  and  trophic  disor- 
ders characteristic  of  myelitis.  Haemorrhage  into  the  cord  is  recog- 
nized by  the  abruptness  of  the  symptoms,  sudden  paralysis  without 
fever  or  other  constitutional  disturbance,  the  loss  of  power  being 
stationary. 

Treatment. — As  in  myelitis  the  symptoms  of  depression  come  on 
so  early,  there  is  rarely  any  need  to  apply  remedies  against  the  conges- 
tion of  the  cord.  The  withdrawal  of  blood,  free  purgatives,  and  other 
antiphlogistic  remedies,  are  of  doubtful  utility.  As  the  ordinary 
modes  of  treatment  have  thus  far  made  no  change  in  the  melancholy 
results  of  this  disease,  the  author  is  the  more  inclined  to  bring  for- 
ward his  own,  which  in  his  hands,  he  states  with  diffidence,  has  accom- 
plished more.  Absolute  rest  and  the  avoidance  of  all  excitement, 
decubitus  on  the  side  or  face,  and  careful  and  nutritious  alimentation, 
are  the  first  measures.  The  frequent  application  of  hot  water  to  the 
spine — preferably  the  hot  douche — is  very  serviceable  ;  in  some  in- 
terval between  these  applications,  a  mustard-plaster  the  length  of 
the  spine  and  four  inches  broad  should  be  put  on,  and  retained  no 
longer  than  beginning  rubefaction,  and  repeated  twice  a  day.  In- 
ternally, quinia  (grs.  iij — grs.  v),  every  four  hours,  with  extract  of 
belladonna  (gr.  ^ — gr.  ss.)  at  the  same  interval,  are  the  most  useful 
remedies. 


CHRONIC   MYELITIS.  QQ-^ 

CHRONIC  MYELITIS. 

Definition. — Under  the  term  chronic  myelitis  are  included  various 
changes  in  the  cord,  of  induration,  sclerosis,  and  gray  or  gelatiniform 
degeneration,  and,  less  often,  of  softening.  These  changes  are  referred 
to  chronic  inflammation,  because  no  other  explanation  is  possible  in 
the  present  state  of  knowledge. 

Causes. — The  causes  of  chronic  are  much  the  same  as  those  of 
acute  myelitis.  It  may  arise  from  the  acute  form  ;  may  be  due  to  in- 
juries, concussions,  blows  on  the  spine  ;  may  result  from  sexual  excess, 
from  exposure  to  cold  and  dampness,  or  from  the  arrest  of  some  habit- 
ual discharge.  The  so-called  reflex  parajjlegias  are  probably  nothing 
more  than  chronic  myelitis,  arising  from  reflex  disturbances. 

Pathological  Anatomy. — The  changes  are  of  several  kinds.  Macro- 
scopically  there  may  be  no  alteration,  or  the  consistence  and  color  may 
be  visibly  changed.  As  to  consistence,  there  may  be  sclerosis  or  soft- 
ening, the  latter  much  less  frequently,  and  in  color  the  change  is  to  a 
grayish  or  yellowish-gray  discoloration — an  evidence  of  the  existence 
of  gray  degeneration.  The  patches  of  sclerosis  may  be  localized,  or 
diffused,  or  disseminated.  The  changes  may  be  limited  to  the  central 
gray  matter,  and  especially  to  that  part  surrounding  the  central  canal, 
or  to  the  gray  matter  of  the  anterior  cornu,  or  to  the  latter  columns 
or  to  the  posterior  columns.  Again,  the  j)eripheral  part  of  the  cord 
may  be  affected  in  conjunction  with  the  pia.*  The  nerve-roots  may 
be  more  or  less  advanced  in  the  gray  or  gelatiniform  degeneration,  the 
nerve-trunks  atrophied,  and  the  muscles  to  which  they  are  distributed 
equally  affected  by  an  atrophic  degeneration,  partly  fatty.  Various 
trophic  changes  occur  in  the  joints  and  mucous  membrane  of  the  gen- 
ito-urinary  tract,  and  bed-sores  form.  The  microscopic  changes  con- 
sist in  an  hyperplasia  of  the  neuroglia — the  fibers  increase  in  number 
and  size,  and  the  cells  undergo  a  nuclear  proliferation.  Various  changes 
occur  in  the  nerve-fibers  :  they  may  be  swollen,  disintegrating,  fatty  ; 
the  axis-cylinder  equally  atrophied  or  indurated.  The  ganglion-cells 
are  shrunken,  pigmented,  indurated,  lose  their  processes,  and  their 
nucleus  and  nucleolus  alike  disappear.  The  vessels  also  undergo  im- 
portant changes  :  the  adventitia  is  indurated,  and  is  the  seat  of  nuclear 
proliferations  and  formation  of  fat-cells,  and  is  thickened  as  well  as 
indurated.  Numerous  fat-granules  and  -cells  and  corpora  amylacea 
are  distributed  through  the  sclerosed  patches. 

Symptoms. — The  symptoms  are  at  first  without  much  significance. 
Disorders  of  sensation  usually  precede  the  motor  disturbances.  There 
are  pains  in  the  limbs  that  have  the  character  of  and  are  usually  con- 
founded with  muscular  rheumatism,  tingling,  mixed  with  numbness, 

*  Vulpian,  "Archives  de  Physiologie,"  tome  ii,  p.  2*79,  "Note  sur  un  cas  de  meningite 
spinal  et  de  sclerose  corticale  annulaire  de  la  moelle  epiniere." 
36 


562  DISEASES  OF  THE  NERVOUS  SYSTEM. 

and  some  burning  ;  pain  in  the  back,  and  a  sense  of  constriction  around 
the  body — the  girdle  or  band  feeling  ;  sometimes  the  integument  over 
the  spine  is  highly  sensitive.  Motor  disturbances  next  appear.  Mus- 
cular fatigue  is  felt  without  exercise,  and  becomes  severe  when  any 
effort,  as  in  walking,  is  made.  The  feet  and  legs  feel  heavy,  and  their 
movements  are  awkward.  With  the  progress  of  the  case,  sensory 
depression,  after  a  time,  supersedes  all  the  symptoms  of  excitation. 
Numbness  is  felt  in  the  fingers  in  the  distribution  of  the  ulnar  nerve, 
in  the  toes,  and  in  the  bottoms  of  the  feet,  which  feel  as  if  a  cushion 
were  interposed  between  them  and  the  floor.  The  various  endowments 
of  the  sensory  nerves  disappear  in  turn — first  the  impression  of  tick- 
ling, then  touch,  pressure,  temperature,  and  finally  pain  (Rosenthal). 
The  anaesthetic  area  is  the  front  part  of  the  thighs,  the  hips  and  loins, 
the  inferior  portion  of  the  body  upward  to  either  side  of  the  abdo- 
men. There  are  parts  below  the  girdle-line  in  which  sensation  is  only 
lessened,  and  parts  that  still  retain  their  normal  sensibility.  Strange 
aberrations  of  sensations  are  observed  in  the  anaesthetic  regions — the 
application  of  heat  may  cause  a  sensation  of  coldness,  of  cold,  a  hot  or 
burning  feeling.  Furthermore,  an  impression  made  at  any  spot  may 
be  referred  by  the  patient  to  some  distant  point,  or  indeed  to  the 
other  side  of  the  body.  The  rate  at  which  impressions  are  transmitted 
from  the  periphery  to  the  centers  of  consciousness  is  much  lessened  in 
this  disease  owing  to  the  obstacles  in  the  paths  of  conduction — sec- 
onds even  being  occupied  in  the  passage  of  an  impression  from  the 
great-toe  to  the  sensorium.  The  paresis  or  paralysis  extends  from 
below  upward,  very  rarely  in  the  opposite  direction.  The  position  of 
the  paralysis  depends  on  the  part  of  the  cord  invaded.  If  the  cervical 
portion,  the  upper  extremities  will  be  the  seat  of  motor  and  sensory 
disorders,  the  pupils  will  be  unequal,  there  will  be  embarrassment  of 
respiration  in  consequence  of  paralysis  of  the  intercostals  and  muscles 
of  the  chest  above,  the  action  of  the  heart  will  be  rapid  and  weak, 
there  will  be  suffocative  attacks,  and  difficulty  in  swallowing.  If  the 
dorso-lumbar  enlargement  be  involved,  there  will  be  the  paralysis  of 
the  lower  limbs  (paraplegia),  of  the  bladder  and  rectum,  the  ele3tro- 
contractility  and  the  reflex  excitability  will  be  both  abolished  ;  but,  if 
above  the  dorso-lumbar  enlargement,  the  reflex  and  electro-contractil- 
ity will  be  rather  heightened.  The  paralyzed  muscles  waste  and  lose 
their  electric  reaction — the  anodal  disappearing  before  the  cathodal 
reaction.  The  sexual  functions  decline  correspondingly.  At  first 
there  is  priapism,  but  the  erections  presently  cease  altogether  ;  yet 
nocturnal  pollutions  occur  from  time  to  time  until  absolute  impotence 
results.  The  urine  is  at  first  frequently  discharged  with  difficulty  ; 
there  may  be  incontinence  and  dribbling,  or  retention  and  a  catheter 
needed.  Constipation  and  meteorism  are  present,  because  the  muscu- 
lar layer  of  the  bowel  is  either  paretic  or  paralyzed.     The  general  nu- 


CHRONIC  MYELITIS.  563 

trition  often  continues  in  a  satisfactory  state  throughout,  but,  in  the 
severe  cases  and  toward  the  end  of  most  cases,  much  suffering  is  ex- 
perienced from  the  wakefulness,  bed-sores,  the  incontinence  of  urine, 
and  the  inflammatory  reaction  from  cystitis  and  pylonephritis. 

Course,  Duration,  and  Termination. — The  development  of  the  disease 
is  slow,  whether  the  chronic  succeeds  to  the  acute  or  originates  de  novo. 
Its  progress  is  slow,  and,  although  varied  by  periods  of  apparent  im- 
provement followed  by  exacerbations,  its  tendency  is  downward.  Nev- 
ertheless, there  are  in  many  cases  long  periods  of  a  perfectly  unchang- 
ing state  in  which  the  damage  done  continues,  and  no  change  for  the 
worse  takes  place  for  many  years.  Even  -in  those  cases  which  seem 
stationary,  there  should  be  not  too  confident  hopes  of  an  arrest,  since 
relapses  may  occur.  In  any  case  there  can  be  no  true  recovery  ;  only 
an  arrest  of  the  morbid  action,  for  the  damage  done  is  permanent. 
There  are  various  modes  of  termination:  by  cystitis,  pylonephritis,  and 
bed-sores,  by  some  intercurrent  malady,  as  pneumonia  or  jjleuritis,  or 
by  the  extension  upward  into  the  cervical  region. 

Diagnosis. — We  have  first  to  distinguish  the  several  forms  of  mye- 
litis, as  regards  the  seat  of  the  lesions  and  the  mode  of  their  progres- 
sion. When  the  cervical  portion  of  the  cord  is  affected,  the  symp- 
toms of  irritation  and  depression  are  seen  in  the  hands  and  arms,  in 
the  disturbances  of  respiration  and  circulation,  in  the  oculo-pupillary 
phenomena,  the  lower  extremities  and  the  sphincters  becoming  affected 
subsequently.  If  the  dorsal  portion  is  affected,  above  the  dorso-lum- 
bar  enlargement,  the  respiration  will  be  affected  by  paralysis  of  the 
intercostals,  the  constricting  girdle  will  be  high  up  about  the  nipples, 
there  will  be  paraplegia  and  paralysis  of  the  sphincters,  but  reflex  and 
electro-contractility  will  not  be  affected,  rather  heightened  than  dimin- 
ished. If  the  lumbar  region  is  affected  in  addition  to  the  symptoms 
of  the  dorsal,  there  will  be  loss  of  reflex  and  electro-contractility  and 
usually  the  trophic  disorders.  When  the  disease  invades  the  multipolar 
cells  of  the  anterior  horns,  it  is  called  poliomyelitis  anterior  chronica, 
the  paralytic  symptoms  occur  as  in  the  disease  of  the  other  parts  of 
the  cord,  but  in  this  region  lesions  produce  trophic  changes  in  the  par- 
alyzed parts,  rapid  wasting  of  the  muscles,  changes  in  the  joints,  bed- 
sores, cystitis,  etc.,  and  loss  of  reflex  and  electro-contractility.  Chronic 
myelitis  is  distinguished  from  haemorrhage  into  the  cord  by  the  sud- 
denness of  the  onset,  and  the  prompt  development  of  paralysis  charac- 
teristic of  the  latter.  From  spinal  meningitis,  by  the  excitation  symp- 
toms, and  the  preservation  of  the  reflexes  and  the  electro-contractility, 
and  the  presence  of  febrile  excitement,  all  wanting  in  chronic  my- 
elitis. 

Treatment. — If  the  disease  is  recent  and  advancing,  rest  takes  the 
first  rank  as  a  remedial  agent.  The  rest  must  be  as  nearly  absolute  as 
possible,  and  should  be  kept  up  for  two  to  three  months  to  be  of  any 


564:  DISEASES   OF   THE   NERVOUS   SYSTEM. 

service.  Erb  *  regards  the  hydropathic  method  as  the  most  success- 
ful ;  the  local  application  of  cold  water  by  compresses  to  the  spine, 
removed  when  they  get  warm  ;  the  "  rubbing  wet  pack,"  the  applica- 
tion restricted  to  the  back  and  body,  hip-baths,  and  the  half -bath,  with 
douches  to  the  spine,  f  The  temperature  of  the  water  should  not 
exceed  80°  Fahr.,  and  should  not  fall  below  55°,  and  the  treatment 
should  not  be  continued  too  long.  If  patients  do  not  react  well  and 
remain  chilly,  the  treatment  does  no  good.  The  author  has  had  re- 
markably good  results  from  the  application  of  the  hot  douche  in  cases 
of  myelitis.  Next  to  hydrotherapy,  galvanism  is  the  most  useful  agent. 
The  important  point,  too  little  understood,  is  the  use  of  a  large  volume 
and  low  tension.  From  forty  to  sixty  elements  of  Siemens  and  Halske 
and  large  sponge  electrodes  well  moistened  are  the  principal  needs. 
The  individual  applications  should  be  about  two  to  five  minutes'  dura- 
tion and  should  be  made  daily.  The  duration  of  the  treatment  will 
be  influenced  by  many  considerations,  by  the  benefit  or  injury  espe- 
cially. Even  if  it  do  good,  the  current  should  not  be  used  daily  for 
months  at  a  time,  but  a  few  days'  intermission  every  month  are  neces- 
sary. The  direction  of  the  current  seems  a  matter  of  indifference,  but 
the  author  believes,  if  the  blood-supply  is  to  be  increased  and  the  nutri- 
tion improved,  that  the  descending  current  is  better.  Nitrate  Of  silver 
has  been  beneficial  in  many  cases.  The  author  has  seen  good  results 
from  the  chloride  of  gold.  Of  all  the  agents  for  the  period  of  depres- 
sion, the  author  regards  the  lactophosphate  of  lime  as  the  most  per- 
manently beneficial.  It  may  be  given  with  arsenic  and  contempora- 
neously with  cod-liver  oil.  The  diet  must  be  light  and  easily  digested, 
especially  so  in  those  cases  undergoing  the  rest-cure.  Spirits  must  be 
forbidden.  One  of  the  most  unpleasant  complications  of  myelitis — in- 
continence of  urine — may  often  be  relieved  by  faradization  of  the  blad- 
der, which  is  best  accomplished  by  introducing  a  button  electrode  into 
the  rectum,  and  applying  a  sponge  electrode  to  the  hypogastric  re- 
gion. 

POSTERIOR    SPINAL    SCLEROSIS— PROGRESSIVE   LOCOMOTOR 

ATAXIA. 

Definition. — Posterior  spinal  sclerosis  is  a  form  of  myelitis,  which 
does  not  extend  transversely  but  longitudinally,  and  is  limited  to  the 
posterior  columns.  The  term  progressive  loeotnotor  ataxia  was  ap- 
plied by  Duchenne  to  designate  the  special  characteristics  of  the  mal- 
ady. This  disease  has  long  been  known  in  Germany  under  the  term 
tcibes  dorsalis. 

Causes. — Probably  the  chief  cause  of  posterior  spinal  sclerosis  is 

*  Ziemssen's  "  Cyclopsedia,"  vol.  xiii,  op.  cit. 

\  See  the  author's  "Materia  Medica  and  Therapeutics,"  third  edition,  article  "Hydro- 
therapy." 


POSTERIOR   SPL\AL   SCLEROSIS.  565 

inherited  tendency.  By  this  is  not  intended  that  the  disease  itself  is 
inherited,  but  a  neuropathic  type,  or  diathesis,  or  constitution.  In 
one  generation  it  may  be  neuralgia,  in  another  epilepsy,  in  another 
locomotor  ataxia.  Some  striking  examples  of  this  disease  appearing 
in  collateral  family  lines  have  been  reported  by  Friedreich.*  It  is 
sometimes  directly  transmitted  ;  thus,  Carre  has  reported  an  instance 
of  one  family,  among  whom  there  were  eighteen  cases  in  three  genera- 
tions.! It  is  a  disease  of  the  most  active  period  of  life,  occurring 
from  twenty  to  sixty,  but  the  cases  are  most  numerous  between 
thirty-five  and  fifty.  It  attacks  males  twice  as  often  as  females. 
Occupations  involving  exposure  to  cold  and  dampness,  to  fatigue, 
and  depressing  moral  emotions,  favor  the  development  of  the  dis- 
ease. It  is  alleged  that  railroad-engine  drivers,  stokers,  conduct- 
ors, and  brakemen,  suffer  from  this  and  other  spinal  diseases  by  rea- 
son of  the  concussion.  There  are  no  statistics  or  exact  observations 
thus  far  published  on  this  point.  Sexual  excesses  are  generally  held 
to  be  influential  in  causing  this  disease,  but,  as  an  unusual  salacity  is 
one  of  the  first  manifestations  of  the  changes  taking  place  in  the  cord, 
there  is  danger  of  confounding  cause  and  effect.  Exposure  to  cold  or 
taking  cold  can,  it  is  probable,  excite  disease  of  this  kind,  only  if  a 
peculiar  state  of  the  nervous  system  is  present.  There  seems  to  be  no 
doubt  that  there  is  a  causative  relation  between  rheumatism  and  loco- 
motor ataxia.J  The  author  has  seen  a  well-marked  case,  produced  in 
a  gilder  by  his  occupation,  the  symptoms  ultimately  disappearing  un- 
der iodide  of  potassium.  It  is  probable  that  the  slow  absorption  of 
the  metals  used  in  the  arts  is  often  responsible  for  the  production  of 
symptoms  similar  to  those  of  posterior  spinal  sclerosis. 

Pathological  Anatomy. — The  meninges  may  be  unaffected,  but  in  a 
majority  of  cases  the  pia  mater  presents  the  appearances  of  increased 
vascularity  along  the  region  of  the  posterior  colunms.  The  form, 
color,  and  consistence  of  the  cord  are  altered.  The  change  consists  in 
an  atrophy  of  the  posterior  columns,  and  hence  there  is  a  shortening 
of  the  antero-posterior  diameter ;  in  a  gray,  semi-transparent,  rather 
vitreous,  amber,  rose  or  reddish-yellow  color,  which  contrast  strongly 
with  the  adjacent  whitish  nervous  matter,  and  in  an  increase  of  the 
consistence  of  the  affected  area,  although  it  may  also  be  softer  than 
normal.  The  extent  of  the  degeneration  varies  in  different  cases, 
but  in  general  it  occupies  the  parts  between  the  posterior  roots,  and  is 
most  considerable  in  the  dorsal  and  upper  lumbar  portion  of  the  cord, 
but  it  may  extend  from  the  filum  terminale  to  the  calamus  scriptorius. 
The  changes,  microscopically  studied,  consist  in  an  hyperplasia  of  the 

*  "TJeber  Ataxie  mit  besonderer  Beriicksichtigung  der  hereditaren  Formen,"  von  Pro- 
fessor Dr.  N.  Friedreich  in  Heidelberg,  Virchow's  "  Archiv,"  Band  Ixviii  und  Ixx. 
f  Erb,  op.  cit. 
X  Topinard,  "De  1' Ataxie  Locomotrice,"  etc.,  Paris,  1864,  p.  363. 


566  DISEASES   OF   THE   NERVOUS   SYSTEM. 

connective  tissues,  a  granular  degeneration,  atrophy,  and  disappear- 
ance of  the  proper  nerve-elements,  the  accumulation  of  fat-cells,  pig- 
ment, and  corpora  amylacea.  The  posterior  roots  are  also  affected  by 
a  fibroid  change — the  connective  tissue  undergoing  development,  the 
nerve-fibers  wasting.  Not  all  parts  of  the  posterior  columns  are  equally 
affected  :  in  the  lumbar  region  the  external  division,  in  the  cervical  the 
inner  and  middle  division  or  the  columns  of  Goll  are  chiefly  diseased. 
Similar  alterations  take  place  in  the  gray  posterior  horns,  and  exten- 
sion of  the  morbid  process  ultimately  is  effected  to  the  lateral  columns. 
The  spinal  ganglia  and  anterior  nerve-roots  escape  degeneration,  as 
also  the  ganglia  of  the  sympathetic  system.  The  gray  degeneration 
often  attacks  the  optic  nerves,  sometimes  the  oculo-motor  and  the 
abducens.  The  joints  undergo  remarkable  changes  :  the  articular  car- 
tilages disappear  by  absorption,  the  head  of  the  bone  and  the  articular 
cavity  gradually  flatten,  atrophy,  and  are  greatly  changed  from  their 
normal  appearance. 

Symptoms. — In  a  man  of  the  middle  period  of  life,  apparently  in 
good  health,  there  appear  from  time  to  time  severe  pains  in  the  body, 
hips,  thigh,  and  leg.  These  are  usually  of  two  kinds — sharp,  quick, 
lightning-like  pains  flying  through  the  limb,  and  a  feeling  of  muscu- 
lar pain,  which  leaves  a  sensation  of  soreness.  These  pains  at  first  are 
occasional  but  after  a  while  they  become  paroxysmal  and  somewhat  more 
frequent,  and  may,  by  the  time  the  other  symptoms  are  defined,  be 
present  more  or  less  every  day,  although  they  may  disappear  for  weeks 
at  a  time.  The  pains  are  increased  by  cold,  especially  by  cold  and 
dampness  combined,  and  are  worse  in  winter.  At  or  before  the  onset 
of  the  pains  there  is  a  marked  increase  in  the  sexual  appetite,  and  men 
are  driven  to  commit  excesses  to  which  they  had  previously  been  stran- 
gers. The  period  of  pains,  with  or  without  increased  sexual  inclina- 
tion, lasts  a  variable  period,  from  a  few  weeks  to  several  years,  and  is 
very  often  diagnosticated  and  treated  as  rheumatism.  These  pains 
are  most  severe  in  those  parts  destined  to  become  ataxic  first,  usually 
the  lower  limbs.  The  next  symptom  is  diplopia,  which  appears  unex- 
jDCctedly  and  after  a  variable  period  of  a  few  weeks  or  a  few  months, 
disappears  as  unaccountably,  although  the  change  is  very  often  attrib- 
uted to  the  remedies  of  some  oculist  consulted  by  the  patient.  Besides 
the  visual  disorder  from  this  cause,  the  eyesight  gradually  becomes 
dim  (amblyopia),  and  further  on,  the  gelatiniform  degeneration  attack- 
ing the  optic  nerve,  vision  is  lost  (amaurosis).  During  this  period  the 
salacity,  which  was  at  first  active,  begins  to  decline  and  nocturnal  sem- 
inal losses  occur.  There  is  also  less  and  less  ability  to  satisfy  the  de- 
sire, the  sexual  congress  becoming  unsatisfactory,  the  erections  inade- 
quate, the  ejaculation  premature,  and  more  or  less  pain  taking  the  place 
of  the  pleasurable  sensations,  and  finally  complete  impotence  results. 
The  first  stage,  according  to  the  definition  of  Duchenne,  consists  of 


POSTERIOR  SPINAL   SCLEROSIS.  567 

three  symptoms  :  pains,  ocular  disorders,  anaphrodisia.  As  already 
remarked,  the  duration  of  this  stage  varies  within  wide  limits — from 
a  few  months  to  several  years,  and  then  begin  the  symptoms  charac- 
teristic of  the  so-called  second  stage  :  numbness  ;  ataxia  of  the  muscu- 
lar movements  of  the  inferior  extremities  ;  cutaneous  and  muscular 
anaesthesia.  In  the  bottoms  of  the  feet  the  numbness  includes  a  sen- 
sation as  if  cotton- wool  or  a  cushion  were  interposed  between  the  feet 
and  the  floor  ;  the  constricting  girdle  sensation  of  spinal  diseases  is 
experienced  around  the  body  at  different  heights  ;  the  limbs,  thighs 
especially,  feel  as  if  embraced  by  a  tight-fitting  cuirass  ;  the  severe, 
lightning-like  pains  rather  increase  than  diminish  ;  the  sense  of  touch 
is  impaired,  so  that  the  points  of  the  ^sthesiometer  can  be  felt  as  two 
only  when  they  are  very  far  apart  ;  impressions  of  irritation  are  slow 
to  reach  the  centers  of  consciousness  ;  the  sense  of  pain  declines  and  is 
entirely  abolished,  but  this  latter  may  be  at  particular  points  only  ;  the 
sense  of  pressure  and  the  sense  of  temperatui-e  are  diminished.  As 
regards  the  motor  functions,  we  find  the  following  characteristic  phe- 
nomena :  at  first  the  limbs  are  easily  fatigued  and  the  movements  are 
uncertain,  so  that  in  walking  the  gait  has  an  unsteadiness  like  that  of 
slight  alcoholic  intoxication,  and  these  unfortunates  are  often  suspected 
of  indulging  in  this  vice  ;  a  sense  of  insecurity  and  often  of  helpless- 
ness, as  when  a  carriage  is  approaching  rapidly,  or  walking  on  a  marble 
or  tiled  floor,  or  in  the  obscurity  of  the  evening,  is  experienced  ;  the 
ataxic  phenomena  increase  so  that  that  they  can  not  stand  with  the 
eyes  closed,  and  in  walking  the  feet  describe  a  semicircle,  the  toes 
pointing  upward  and  outward,  the  heels  coming  down  with  a  stamp. 
An  examination  of  the  muscles  now  discloses  that  the  disorder  of  loco- 
motion is  an  ataxia  :  the  muscles  are  not  weak  at  first,  and  very  great 
ataxia  may  coexist  with  complete  retention  of  muscular  power,  but 
presently  some  of  the  muscles  become  paretic,  and  ultimately  there 
may  be  paralysis  with  wasting.  They  can  not  at  first  walk  without  the 
aid  of  vision  ;  after  a  time  the  assistance  of  a  cane  is  needed  besides 
their  eyes,  then  two  canes  are  found  necessary,  and  finally  walking 
has  to  be  abandoned.  In  Duchenne's  rather  arbitrary  arrangement 
the  third  stage  consists  in  the  extension  of  the  sensory  and  motor  dis- 
turbances to  the  upper  extremities.  The  order  of  phenomena  is  as  fol- 
lows :  pains,  numbness,  first  in  the  ulnar-nerve  region,  then  extending 
to  all  the  fingers,  troubles  of  coordination,  inability  to  use  the  knife 
and  fork,  to  fasten  a  button,  etc.  The  reflexes  are  variously  affected 
— sometimes  increased,  sometimes  lessened,  sometimes  wanting.  The 
patella  tendon  reflex  is  abolished.  Electro-contractility  is  increased 
or  normal,  and  reduced  or  lost  when  muscles  degenerate. 

During  the  pi'ogress  of  the  case,  usually  the  vegetative  functions 
are  well  performed.  The  appetite  remains  good,  and  the  nutrition 
does  not  fail  ;  the  patients  often  having  a  rosy  countenance  and  a 


568  DISEASES  OF  THE  NERVOUS  SYSTEM.. 

self-satisfied  expression,  which  lends  countenance  to  the  theory  of 
secret  drinking.  The  mental  functions  continue  unaffected,  and  the 
moral  state  is  one  of  contentment,  although  there  may  be  great  de- 
pression of  spirits.  There  are  peculiarities  in  the  symptoms,  not  in- 
cluded in  the  preceding  description,  to  which  some  attention  should  be 
paid.  The  anaesthesia  of  the  soles  of  the  feet  is  an  element  in  the 
disorders  of  movement  in  walking.  Some  patients  with  entire  anal- 
gesia, so  that  a  pin  can  be  driven  into  the  flesh  without  any  sensation 
whatever,  suffer  agony  with  a  gentle  touch,  as  the  brushing  of  a  wo- 
man's dress  against  the  legs.  It  is  in  spots  that  such  sensations  exist. 
The  place  where  a  lightning-pain  has  just  been  felt  often  burns  for 
some  time  after.  One  of  the  most  disagreeable  disorders  of  sensation 
is  the  feeling  of  "  fidgets,"  a  peculiar  unrest  which  impels  to  move- 
ment. The  muscular  sensibility  is  m.uch  reduced.  The  muscular 
sense,  the  knowledge  of  the  position  of  the  members,  and  the  appre- 
ciation of  weight  and  resistance,  are  all  reduced  or  abolished,  and  con- 
sequently the  disorders  of  muscular  action  of  every  kind  are  enhanced. 
The  ataxia  of  movement  is  particularly  well  exhibited  when  the  patient, 
lying  recumbent,  is  told  to  touch  objects  with  his  foot.  The  move- 
ments are  in  jerks,  great  energy  is  put  into  them,  but  the  direction  is 
irregular  and  apparently  purposeless.  Ataxia  affects  the  muscles  of 
the  eye,  as  well  as  of  the  extremities,  producing  the  effect  called  nys- 
tagmus, disordered  accommodation,  and  changes  in  the  size  of  the 
pupils.  Friedreich's  bilateral  nystagmus  consists  of  jactitating  move- 
ments in  a  vertical,  horizontal,  or  oblique  direction,  not  when  the  eye 
is  at  rest,  but  when  an  attempt  is  made  to  fix  it.  Besides  these  motor 
disturbances,  vision  is  affected  by  gelatiniform  degeneration  of  the 
optic  nerve,  in  a  variety  of  ways — in  respect  to  the  size  and  sharpness 
of  the  field  of  vision  and  the  appreciation  of  colors,  the  ultimate  result 
being  white  atrophy  of  the  optic  disks.  Various  trophic  alterations 
occur  during  the  course  of  locomotor  ataxia,  especially  toward  the  end. 
The  most  important,  which  has  already  been  referred  to,  are  the  joint 
affections,  beginning  usually  in  the  knee-joint.  These  changes  may 
indeed  begin  before  the  ataxia,  during  the  first  stage,  and  involve  the 
shoulder,  elbow,  and  wrist,  as  well  as  the  knee  and  hip.  There  occurs 
first,  in  the  joint,  swelling  due  not  to  any  inflammatory  process,  but 
the  mere  accumulation  of  fluid,  without  pain  or  tenderness.  The 
swelling  may  spontaneously  disappear,  but  usually  important  and 
destructive  alterations  occur  in  the  joint — the  cartilages  are  destroyed, 
the  ends  of  the  bones  worn  off,  and  partial  and  entire  luxation  results.* 
The  bones  of  the  body  of  an  ataxic  manifest  an  extreme  fragility  and 
break  easily. 

*  "Diseases  of  the  Nervous  System,"  by  J.  M.  Charcot,  Syd.  Soc.  ed.,  London,  IS'??, 
p.  91.  See  also  "  Spinal  Arthropathies,"  by  Weir  Mitchell,  "  American  Journal  of  the 
Medical  Sciences,"  April,  1875. 


POSTERIOR   SPINAL   SCLEROSIS.  569 

Course,  Duration,  and  Termination. — Beginning  obscurely  and  de- 
veloping slowly,  it  may  be  years  before  the  character  of  the  symptoms 
will  justify  the  attempt  at  a  diagnosis.  The  first  stage  lasts  from  sev- 
eral months  to  several  years.  The  ataxic  disorders  usually  begin  in 
the  lower  extremities,  and  the  pains  are  most  severe  in  the  part  or 
member  destined  to  become  ataxic.  It  occasionally  happens  that  the 
incoordination  begins  in  the  upper  extremities.  The  second  stage  is 
even  more  protracted  than  the  first,  and  its  duration  is  an  aifair  of 
years.  When  extension  takes  place  to  the  upper  extremity,  the  prog- 
ress is  usually  more  rapid.  The  whole  duration  of  the  disease  is  on 
the  average  seven  years  (Topinard),  but  many  continue  thirty  years. 
The  shortest  duration  of  a  well-observed  and  carefully  recorded  case 
is  three  years.  The  progress  is  affected  by  the  seasons,  the  atmos- 
pherical conditions,  and  by  the  regimen.  Sometimes  ameliorations 
occur  without  any  apparent  cause,  or  the  disease  remains  absolutely 
stationary  for  long  periods  ;  then  exacerbations  are  experienced.  The 
final  result  may  be  determined  by  acute  congestion  or  softening  of  the 
cord,  by  cerebral  diseases,  by  extension  to  the  anterior  cornua  and  the 
evolution  of  progressive  muscular  atrophy,  by  gastro-intestinal  inflam- 
mation, by  cystitis  and  pylonephritis,  by  bed-sores,  and  by  various 
intercurrent  diseases.  The  most  frequent  of  the  intercurrent  maladies 
is  phthisis,  for  we  find  that,  in  a  collection  of  forty-three  cases,  thirteen 
were  terminated  by  consumption,  four  by  broncho-pulmonary  inflam- 
mations, two  by  enteritis,  three  by  typhoid  fever,  etc.  That  a  cure  of 
a  genuine  case,  extended  to  the  second  stage,  is  ever  affected,  seems 
very  doubtful.  That  the  disease  may  be  arrested,  after  more  or  less 
damage  has  been  inflicted,  is  perfectly  true.  The  author  has  men- 
tioned a  case  in  which  all  the  symptoms  of  the  second  stage  were  pres- 
ent, and  which  recovered  completely  under  iodide  of  potassium,  but 
the  patient  was  a  gilder. 

Diagnosis. — The  recognition  of  this  disease  is  easy  when  fully 
developed.  During  the  first  stage,  the  pains  may  not  be  different 
from  those  of  rheumatism  or  myalgia,  but  the  occurrence  of  double 
vision  and  of  sexual  disorders  should  suggest  their  real  character.  At 
this  period  the  sexual  disorders  are  confounded  with  "  seminal  weak- 
ness," but  the  diagnosis  ought  to  be  made,  by  the  pains,  the  double 
vision,  and  the  time  of  life  at  which  the  nocturnal  losses  began.  From 
all  acute  affections  of  the  spinal  cord  this  disease  is  separated  by  the 
exceeding  slowness  of  its  development  as  well  as  by  the  character  of 
the  attendant  phenomena.  From  chronic  myelitis  and  all  other  affec- 
tions of  the  cord,  accompanied  by  paraplegia,  with  or  without  wasting, 
locomotor  ataxia  is  differentiated  by  the  condition  of  ataxia.  In  the 
one,  the  muscles  are  paralyzed  ;  in  the  other,  they  are  not  paralyzed, 
but  incoordinate.  These  coarse  phenomena  seem  sufficient  wdthout 
entering  into  the  numerous  finer  points  of  difference. 


570  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Treatment. — The  first  of  all  remedies  is  rest,  and  as  nearly  absolute 
rest  as  possible.  The  results  accomplished  in  this  way  are  remarkable. 
The  patient  should  avoid  all  use  of  his  muscles,  and  should  remain 
recumbent  for  Aveeks.  The  rest-cure  involves  the  complete  severance 
from  all  cares,  occupations,  and  movements  for  a  period  of  two  or 
three  months,  and  subsequently  greatly  modified  occupation  and 
movement  for  some  months  longer.  The  position  should  be  on  one 
side  and  toward  the  face  as  much  as  possible,  and  on  a  firm  bed  or 
lounge,  without  any  constricting  clothing.  The  diet  must  be  light 
and  simple,  corresponding  to  the  changed  necessities  of  the  organism. 
Coffee,  tea,  tobacco,  and  alcoholic  stimulants  should  be  given  up. 
Next  to  rest  in  imj^ortance  is  the  cold-water  cure,  which  may  be  well 
conjoined  with  the  rest-cure,  and  thus  serve  a  double  purpose.  Erb 
says  the  "  thermal  baths  "  are  hurtful,  but  that  the  results  of  the  "  cold- 
water  baths  are  extraordinarily  favorable.  ...  Of  nineteen  tabes  pa- 
tients who  went  through  with  the  cold-water  cure,  sixteen  experienced 
more  or  less  benefit,  two  saw  no  improvement,  and  only  one  grew  slightly 
worse.  The  temperature  of  the  water  must  not  be  below  68°  Fahr., 
nor  above  88°  Fahr.,  and  the  application  should  consist  of  the  rubbing 
wet  pack  confined  to  the  spine,  the  wet  cold  compress  applied  along 
the  spine  for  some  minutes,  and  cold  sponging  of  the  spine,  all  cold 
douches  and  full  baths  being  avoided.  The  treatment  may  be  con- 
ducted better  at  home,  if  the  patients  are  provided  with  the  means. 
The  springs  of  our  mountain-regions  of  Virginia,  Pennsylvania,  New 
York,  etc.,  may  be  advised  during  the  summeT  and  fall,  the  tempera- 
ture and  not  the  co7nposition  of  the  water  being  heeded.  The  author 
has  seen  a  great  deal  of  injury  done  by  the  hot  springs  of  Arkansas  in 
this  disease.  The  third  remedy  is  galvanism,  direct  continuous  cur- 
rents to  the  spine,  labile  applications  to  the  extremities  for  the  relief 
of  pain,  faradic  currents  to  wasting  muscles,  and  to  the  bladder  if 
paralyzed.  As  regards  the  internal  medicines,  the  use  of  iodide  of 
potassium  is  proper  in  every  case  for  a  short  time,  lest  there  may  be  a 
syphilitic  or  metallic  lesion  of  the  cord.  If  no  results  follow  in  two 
or  three  weeks,  a  continuation  of  the  remedy  will  not  be  advantageous. 
If  there  be  a  decided  decline  of  the  vital  powers,  the  best  results  are 
obtained  from  lactophosphate  of  lime  and  cod-liver  oil.  Nitrate  of 
silver  has  been  serviceable  in  many  cases,  and  is  placed  first  as  a 
remedy  by  some  great  authorities,  but  the  danger  of  staining  the 
tissues  of  the  body  is  very  great.  Phosphorus  has  produced  good 
effects  in  the  hands  of  Dujardin-Beaumetz,  but  has  been  less  useful  in 
the  experience  of  others.  Belladonna  and  ergot  have  been  urged  by 
Trousseau  and  Brown-Sequard,  but  the  author,  although  he  has  tried 
them,  has  been  disappointed. 


LATERAL  SCLEROSIS.  571 

LATERAL    SPINAL    SCLEROSIS. 

Definition. — This  term  is  employed  for  uniformity  to  express  a  dis- 
ease having  similar  lesions  to  those  of  posterior  spinal  sclerosis  but  a 
different  seat.  By  Charcot  this  disease  is  named  spasmodic  tabes  dor- 
salis,  and  by  Erb  spastic  spinal  paralysis. 

Pathogeny. — Lateral  spinal  sclerosis  develops  under  the  same  con- 
ditions as  posterior  spinal  sclerosis.  The  site  of  the  lesions  is  the  lat- 
eral white  columns,  and  the  changes  consist  in  the  gray  gelatiniform 
degeneration.  There  occurs  an  interstitial  hyperplasia  of  the  connec- 
'tive  tissue,  and  an  atroj^hy  of  the  proper  nerve-elements.  Although 
it  chiefly  affects  the  posterior  part  of  the  lateral  column,  it  may  ex- 
tend forward  to  the  anterior  horn  (its  external  angle),  posteriorly  to 
the  posterior  gray  matter,  and  internally  to  the  deepest  portion  of  the 
lateral  columns  (Charcot).  Secondary  degeneration  of  the  lateral  col- 
umns, which  occurs  in  certain  cerebral  diseases,  is  found  on  one  side 
only.  In  the  disease  described  by  Charcot  under  the  name  amyotro- 
2)hic  lateral  sclerosis,  to  the  sclerosis  of  the  lateral  columns  are  added 
atrophy  and  disappearance  of  the  multipolar  ganglion-cells  of  the  ante- 
rior cornua.  This  form  of  spinal  sclerosis  is  situated  in  the  cervical  en- 
largement by  preference  (Erb).  Lateral  spinal  sclerosis  has  its  seat 
in  the  whole  length  of  the  cord — from  the  lumbar  region  up  to  the 
medulla  oblongata. 

Symptoms. — The  symptoms  of  this  disease  are  peculiarly  striking, 
in  that  paraplegia  exists  with  motor  irritation.  Before  the  motor 
symptoms  there  may  be  present  such  sensory  disturbances  as  pain  in 
the  back,  tingling,  formication,  and  "tearing  pains,"  but  these  are 
usually  transient.  The  irritation  symptoms  are  motor,  and  consist  of 
jerking  and  twitching,  cramps,  and  stiffness  of  the  muscles,  felt  espe- 
cially after  fatiguing  exercise,  and  at  night  on  lying  down.  The 
muscles  gradually  become  very  tense,  and  certain  movements  diffi- 
cult in  consequence.  Because  of  the  continuous  tonic  contractions 
of  the  muscles  the  knees  seem  stiff,  the  step  is  shortened,  and  the 
legs  approximated.  The  gait  is  a  hop,  the  patient  stepping  on  the 
toes,  and  showing  a  tendency  to  fall  forward.  This  peculiarity  of 
muscular  movement  is  due,  not  altogether  to  the  tonic  extension  state 
of  the  muscles,  but  to  paresis.  At  first  there  is  a  feeling  of  heaviness 
and  weakness,  the  muscles  becoming  very  tired  on  slight  exertion, 
and  this  passes  on  into  paresis,  only  in  very  rare  cases  into  paralysis. 
When  the  point  of  the  foot  rests  on  the .  floor,  the  patient  sitting,  a 
tremor  of  the  limb  is  produced.  The  tendon  reflexes  in  this  disease 
are  much  exaggerated.  The  sensibility  is  unaffected  ;  there  is  no 
atrophy  of  the  muscles  ;  and  the  functions  of  the  rectum,  bladder,  and 
sexual  system  remain  unaltered.  The  disease,  beginning  below,  ex- 
tends gradually  upward.      When  the  muscles  of  the  trunk  become 


572  DISEASES  OF  THE  NERVOUS  SYSTEM. 

affected,  sitting  up,  or  rising  from  the  recumbent  to  the  upright  posture 
becomes  difficult,  finally  impossible.  When  the  arms  are  involved, 
the  same  combined  weakness  and  rigidity,  increase  of  the  reflexes, 
paresis  and  contractures  occur.  But  there  are  no  symptoms  of  ataxia, 
and  paralysis  only  rarely  results.  Sometimes  the  disease  assumes  a 
hemiplegic  form,  passing  from  one  lower  extremity  to  the  correspond- 
ing upper  extremity.  When  the  disease  completes  its  development, 
so  to  speak,  it  remains  nearly  stationary  for  many  years,  yet  in  most 
cases,  ultimately,  the  contractures  increase,  and  the  paralysis  becomes 
complete,  and  the  patient  is  then  entirely  disabled.  Nevertheless 
the  malady  does  not  prove  fatal  of  itself,  the  termination  being  by 
some  intercurrent  disease.  In  that  form  of  anterior  spinal  sclerosis 
in  which  the  lesions  involve  the  anterior  cornua,  and  which  is  accom- 
panied by  progressive  muscular  atrophy,  the  symptoms  present  are 
those  of  anterior  spinal  sclerosis  and  progressive  muscular  atrophy.* 
As  the  anatomical  site  of  the  disease  is  the  cervical  portion  of  the 
cord,  the  symptoms  first  produced  are  those  of  the  upper  extremities. 
The  muscles  of  the  arms  are  occupied  by  fibrillary  contractions,  are 
wasted,  paretic,  but  still  retain  the  electro-contractility.  The  muscles 
of  the  arms,  jaws,  and  neck  are  also  in  a  state  of  tonic  contraction 
passing  into  contractures,  which  ultimately  disappear  when  the 
changes  in  the  muscles  are  complete.  In  from  four  months  to  a  year 
both  arms  are  fully  affected,  and  then  extension  takes  place  to  the 
lower  extremities.  The  same  phenomena  of  paresis  and  rigidity  with 
wasting  take  place  in  the  lowei*  extremities,  but  the  bladder  and  rec- 
tum are  not  affected.  Then  occur  also  in  the  lower  limbs  the  fibril- 
lary contractions  and  clonic  spasms,  with  permanent  muscular  rigidity, 
which  are  characteristic  of  this  disease.  In  the  third  stage,  the  field 
of  morbid  activity  is  transferred  to  the  medulla  oblongata.  Respira- 
tory and  circulatory  disturbances  then  ensue,  and  death  speedily  oc- 
curs. The  whole  course  of  this  disease  is  completed  in  from  two  to 
three  years. 

Diagnosis. — The  main  points  of  difference  between  posterior  and 
anterolateral  spinal  sclerosis  have  been  referred  to  in  passing  ;  the 
presence  of  the  reflexes,  the  absence  of  all  symptoms  of  ataxia,  weak- 
ness instead  of  incoordination,  the  contractures  and  clonic  spasms  in 
the  anterolateral  sclerosis,  are  absent  in  the  posterior  sclerosis. 

Treatment. — The  principles  and  methods  of  treatment  are  the  same 
as  in  posterior  spinal  sclerosis,  which  have  been  sufficiently  set  forth  in 
the  preceding  chapter. 

*  "  Deux  cas  d'atrophie  musculaire  progressive  avec  lesions  de  la  substance  grise  et 
dea  faisceaux  anterolateraux  de  la  moelle  epini^re,"  par  MM.  J.  M.  Charcot  et  A.  Jof- 
froy,  "  Archives  de  Physiologic,"  vol.  ii,  1869,  p.  354,  et  seq. 


INFANTILE   PARALYSIS.  573 

INFANTILE   PARALYSIS— POLIOMYELITIS  ANTERIOR    ACUTA. 

Definition. — By  infantile  jiaraly sis  is  meant  a  peculiar  form  of  spi- 
nal paralysis,  occurring  in  children  suddenly,  and  due  to  an  inflamma- 
tion of  the  anterior  horns  of  gray  matter.  It  is  now  known  that  the 
same  form  of  disease  occurs  in  adults  also,  though  much  less  often. 

Causes. — Infantile  paralysis,  as  the  name  implies,  is  a  disease  of 
early  life,  and  occurs  most  frequently  from  six  months  to  the  fourth 
year  ;  but  precisely  the  same  form  of  disease  occasionally  is  encoun- 
tered up  to  sixty  years  of  age,  so  that  the  term  proposed  by  Kussmaul 
— poliomyelitis  anterior  acuta — is  more  appropriate.  Besides  age,  lit- 
tle is  known  as  to  the  causes  producing  this  disease.  The  influence  of 
summer  heat  seems  established  by  the  observations  of  Sinkler.*  As 
cases  frequently  occur  during  the  course  of  convalescence  from  the 
exanthemata,  and  other  acute  febrile  affections,  a  causative  relation  is 
supposed  to  exist  between  them.  The  important  negative  fact,  that 
the  influence  of  heredity  can  not  be  traced,  must  be  stated. 

Pathological  Anatomy. — The  naked-eye  appearances  furnish  no  ex- 
act information,  and  may  be  entirely  negative.  On  microscopic  ex- 
amination, important  changes  are  found  in  the  anterior  horns  of  gray 
matter,  in  the  dorso-lumbar  and  cervical  enlargements  of  the  cord. 
The  change  consists  in  an  inflammatory  softening  ;  the  nerve-elements 
are  disassociated  by  an  exudation  containing  numerous  granulation  cor- 
puscles and  free  nuclei ;  the  neuroglia  undergoes  hyperplasia,  and  the 
blood-vessels  are  abnormally  distended  ;  the  multipolar  ganglion-cells 
have  wasted,  and  many  disappeared,  while  those  remaining  are  in 
varioiis  stages  of  atrophic  degeneration.  The  softening  occurs  in  cer- 
tain areas,  from  a  half -inch  to  an  inch  in  length,  and  on  both  sides,  or 
on  one  side  only,  and  especially  in  the  dorso-lumbar  enlargement. 
The  softening  extends  a  little  posteriorly  and  laterally,  and  sclerotic 
degeneration  also  occurs  in  the  adjacent  antero-lateral  columns.  Sim- 
ilar changes  take  place  in  the  anterior  roots.  Extensive  wasting,  atro- 
phic degeneration,  and  sclerosis,  occur  in  all  cases  and  after  many 
years.  The  anterior  nerve-roots  are  thin,  atrophied,  and  translucent, 
and  more  or  less  degeneration  takes  place  in  the  filaments  of  the  pe- 
ripheral nerves.  The  muscles  to  which  the  nerves  are  distributed 
undergo  very  serious  alterations,  which  consist  in  an  increase  of  the 
connective  tissue,  the  formation  of  numerous  fat-cells  and  -granules, 
and  the  degeneration  and  disappearance  of  the  muscular  fibers.  The 
bones  of  the  paralyzed  members  cease  to  grow,  and  degenerate  more 
or  less,  the  cancellated  structure  being  relatively  increased,  and  the 
fatty  tissue  also.  Important  changes  occur  in  the  joints  ;  the  articu- 
lar  surfaces  are  atrophied  and   eroded,  the  ligaments   thinned   and 

*  "  American  Journal  of  the  Medical  Sciences,"  vol.  Ixix,  p.  348. 


Hi 


574  DISEASES   OF   THE   XERVOUS   SYSTEM. 

stretched,  tlie  articulations  relaxed.  By  reason  of  these  atrophic 
changes  great  deformities,  the  worst  forms  of  club -foot,  are  produced. 
Symptoms. — The  usual  onset  of  this  disease  is  a  fever,  which  lasts 
a  day  or  two,  and  on  recovery  from  which  it  is  observed,  with  sur- 
prise, that  the  child  is  paralyzed.  The  fever  may  be  accompanied 
with  headache,  pain  in  the  back  and  limbs,  with  vertigo  and  delirium, 
in  some  cases  with  convulsions.  Dr.  Mary  Putnam-Jacobi  *  has  ana- 
lyzed one  hundred  and  sixty-three  cases,  and  finds  that  there  are  sev- 
eral modes  of  onset.  In  twelve  of  these  cases  the  paralysis  occurred 
suddenly  without  any  prodromes  ;  in  some  cases  the  paralysis  appears 
in  the  morning  after  a  quiet  night,  or  between  morning  and  evening, 
without  symptoms  ;  in  the  majority  of  cases  there  is  an  attack  of  fever 
lasting  two  or  three  days  ;  in  some,  merely  nausea  and  vomiting,  and 
in  still  others  the  paralysis  is  preceded  by  convulsions.  What  symp- 
toms soever  may  precede  the  palsy,  they  subside  in  a  day,  or  in  two  or 
three  days,  and  the  health  seems  restored,  but  one  limb  or  several  are 
found  to  be  paralyzed  ;  or  one  leg  is  limp  and  motionless,  and  in  an  hour 
or  two  the  other  leg  is  found  to  be  in  the  same  condition  ;  and,  in  the 
course  of  the  next  twenty-four  hours,  the  arms  may  also  be  paralyzed. 
From  the  beginning  of  the  symptoms  until  the  paralysis  is  completed, 
rarely  more  than  a  week  is  required.  The  bladder  may  participate  in 
the  paralysis,  and  the  urine  be  retained,  or  there  may  be  incontinence, 
but  the  bladder  is  not  permanently  affected,  and  these  troubles  disap- 
pear in  a  few  days  or  weeks.  Sensibility  is  not  affected.  The  pa- 
ralysis is  complete  at  once,  and  soon  begins  to  lessen,  some  restoration 
of  power  taking  place  in  from  one  to  three  weeks,  which  may  gradu- 
ally go  on  until  the  paralyzed  parts  are  completely  restored  m  the 
course  of  a  few  months.  During  this  period  the  electro-contractility 
and  the  nutrition  of  the  muscles  are  not  affected  in  this  group  of  cases, 
although  the  muscles  are  flabby  and  soft.  Most  of  the  cases  behave 
differently.  Improvement  begins  as  in  the  cases  just  narrated,  but 
it  proceeds  to  a  certain  point  only  ;  some  of  the  members  recover 
entirely,  leaving  one  or  more  or  a  single  group  of  muscles  affected. 
Thus  the  arms  may  be  restored  and  the  lower  limbs  continue  paralyzed, 
or  one  arm  or  one  leg  may  remain  disabled.  Rarely  is  one  half  of  the 
body  (hemiplegia)  affected,  and,  if  such  be  the  case,  the  cause  is  to  be 
sought  within  the  cranium.  When  an  arm  is  alone  affected,  the  ex- 
tensors of  the  arm  and  fingers  are  paralyzed  ;  when  the  lower  limbs 
are  involved,  the  disability  is  in  the  extensors  of  the  thigh  (the  psoas, 
Rosenthal),  or  in  the  muscles  supplied  by  the  peroneal  nerve.  The 
muscles  remaining  paralyzed  are  affected  permanently,  and  by  a  rap- 
idly progressive  atrophy  ;  the  tendon  and  other  reflexes  and  the  elec- 
tro-contractility to  the  faradic  current  are  abolished.     The  tempera- 

*  "The  American  Journal  of  Obstetrics,"  June,  1874. 


INFANTILE   PARALYSIS.  575 

ture  of  the  paralyzed  part  falls  several  degrees  ;  they  become  cool  to 
the  touch,  and  present  a  blue,  cyanosed  appearance.  The  muscles 
waste  till  there  is  nothing  but  connective  tissue  and  fat,  the  joints 
change  in  form  and  structure,  the  growth  of  the  limb  is  arrested,  and, 
if  one  of  the  lower  limbs  is  deformed,  assuming  often  one  of  the  forms 
of  club-foot.  Seguin*  has  given  a  careful  analysis  of  many  of  the 
cases  of  spinal  paralysis  (poliomyelitis  anterior  acuta),  which  have  been 
published.  The  following  symptoms  he  regards  as  characteristic  : 
"  Dysesthesia,  and  slight  temporary  anaesthesia,  paresis  and  akinesis, 
both  these  symptoms  affecting  the  extremities,  and  in  rare  cases  the 
eyes,  face,  tongue,  and  throat ;  not  affecting  the  respiratory  muscles, 
nor  those  of  the  back  and  abdomen,  nor  the  bladder,  nor  the  sphincter 
ani.  Muscular  atrophy  in  the  paralyzed  parts.  Loss  of  electro-mus- 
cular contractility  (to  faradic  current)  in  the  atrophied  muscles.  A 
strong  tendency  to  spontaneous  retrocession  of  the  palsy,  and  to  spon- 
taneous cure.  The  important  negative  characters  of  this  affection  are  : 
absence  of  palsy  of  the  bladder,  or  of  the  sphincter  ani,  or  of  the  re- 
spiratory muscles  ;  no  bed-sores  ;  no  great  and  extensive  anaesthesia  ; 
no  spinal  epilepsy." 

Course,  Duration,  and  Termination. — The  course  of  the  disease  is 
very  uniform.  The  mildest  cases,  in  which  restoration  of  power 
begins  in  a  few  days,  recover  entirely  in  a  few  weeks  or  in  a  month  or 
two.  These  cases  have  been  designated  "temporary  paralysis."  Other 
cases,  in  which  a  single  member  or  a  group  of  muscles  remains  para- 
lyzed after  the  efforts  at  restoration  have  ceased,  may  regain  the  lost 
power  in  from  two  to  six  months.  If  the  restoration  does  not  take 
place  within  this  time,  it  becomes  less  and  less  likely  with  the  increas- 
ing duration  of  the  case.  Partial  restoration  is  the  rule  even  in  favor- 
able cases.  Much  depends  on  the  treatment.  So  far  as  danger  to 
life  is  concerned,  the  prognosis  is  always  favorable.  So  far  as  ulti- 
mate entire  restoration  is  concerned,  the  prognosis  is  unfavorable. 
Persistent  and  rightly  conducted  electrical  treatment  may  accomplish 
much  even  in  unfavorable  cases. 

Diagnosis. — The  first  point  in  diagnosis  is  the  condition  of  the 
paralyzed  muscles.  If  wasted,  how  far  do  the  muscular  elements  exist  ? 
This  is  ascertained  by  electrical  tests.  In  these  cases  the  muscles  do 
not  respond  to  a  faradic  current,  but  will  contract  on  the  application  of 
a  weak  and  slowly  interrupted  galvanic.  Muscular  contraction  is  the 
proof  of  the  presence  of  the  muscular  elements.  By  the  use  of  the 
harpoon,  some  portion  of  the  tissue  may  be  withdrawn  and  submitted 
to  a  microscopic  examination.  Infantile  paralysis  may  be  confounded 
with  acute  myelitis,  haemorrhage  into  the  cord,  progressive  muscular 
atrophy,  paralysis  from  cerebral  affections  in  childhood  and  paralysis 

*  "  Spinal  Paralysis  of  the  Adult,"  New  York,  1874,  p.  27. 


576  DISEASES   OF   THE   NERVOUS   SYSTEM. 

from  local  nerve-lesions.  From  mj^elitis  the  distinction  is  made  by 
the  stage  of  excitation  affecting  sensibility  and  motility,  and  the  stage 
of  depression  also  affecting  sensibility  and  motility  and  the  bladder. 
From  haemorrhage,  the  distinction  is  made  first  on  account  of  its 
rarity,  next  the  suddenness  of  the  attack,  sensibility  being  destroyed 
as  well  as  motility,  usually,  and  the  sphincters  paralyzed.  From  pro- 
gressive muscular  atrophy,  the  distinction  is  made  by  the  age  of  the 
subject,  the  slow  development,  and  the  affection  of  isolated  muscular 
groups  in  turn.  From  cerebral  lesions,  the  distinction  is  made  by  the 
pronounced  cerebral  symptoms,  by  the  hemiplegia,  by  the  electrical 
reaction,  the  electro-contractility  rather  heightened  than  lost,  and  by 
the  appearance  and  condition  of  the  paralyzed  members.  From  pa- 
ralyses due  to  local  injury  of  nerve,  the  distinction  is  made  by  the  his- 
tory of  the  case,  the  evidence  of  injury,  by  the  absence  of  fever,  by 
the  diffusion  of  the  paralysis  at  first,  followed  by  localization. 

Treatment. — During  the  attack  of  fever  with  which  the  disease 
begins,  only  symptomatic  treatment  is  proper,  since  a  diagnosis  is  not 
possible.  When  paralysis  has  occurred  the  damage  to  the  cord  is  com- 
plete, but,  as  the  functional  disturbance  is  more  extensive  than  the 
symptomatic  expression  of  the  real  lesions,  the  improvement  which 
follows  from  the  first  paralysis  is  simply  the  disappearance  of  the 
merely  functional  troubles.  Any  active  treatment,  therefore,  insti- 
tuted with  a  view  of  combating  an  inflammation,  is  improperly  ap- 
plied. The  problem  is  to  prevent  further  destruction  of  the  gray  mat- 
ter, and  to  restore  damaged  but  still  functionally  capable  tissue.  The 
remedies  best  adapted  to  accomplish  this,  and  which  in  the  author's 
hands  have  acted  best,  are  quinia  and  belladonna  (from  a  fourth  to 
four  grains,  according  to  age,  of  quinia,  and  from  ^  to  ^  grain  of  bel- 
ladonna extract) ;  hot  douche  to  the  spine  and  tepid  wet  packs ;  the 
application  of  galvanism,  inverse  current,  stabile,  large  volume  and 
low  intensity,  and  rest,  as  nearly  absolute  as  possible,  until  the  period 
of  restoration.  When  the  period  of  improvement  comes  on,  the  mus- 
cles must  be  faradized,  if  they  react  to  the  faradic  current,  or  gal- 
vanized if  they  react  only  to  the  galvanic  current.  Massage  is  suitably 
combined  with  electrical  treatment.  The  wasted  muscles  are  much 
improved  by  aquapuncture  ;  still  more  by  the  intramuscular  injection 
of  strychnia  (^-i-g — -gL-  grain)  two  or  three  times  a  week.  The  injec- 
tions of  strychnia  should  not  be  practiced  until  after  the  period  of  res- 
toration— the  stationary  period. 

PROGRESSIVE  MUSCULAR  ATROPHY. 

Definition, — By  the  term  progressive  muscular  atrophy  is  meant  a 
gradual  and  progressive  wasting  of  the  voluntary  muscular  system, 
which  pursues  a  certain  defined  course. 


PROGRESSIVE   MUSCULAR  ATROPHY.  5^7 

Causes. — Numerous  examples  of  hereditary  transmission,  some  of 
them  very  remarkable,  have  been  reported.  The  male  sex  is  much 
more  susceptible,  and  this  is  equally  the  case  when  the  disease  is  he- 
reditary. The  most  active  period  of  life — from  thirty  to  fifty — is  the 
period  of  greatest  liability  ;  but  youth  and  early  manhood  are  by  no 
means  exempt,  cases  occurring  before  ten.  Powerful  muscular  exer- 
tion, or  overstrain  of  a  group  of  muscles  in  certain  occupations,  seems 
to  excite  the  disease  ;  and  in  children  the  disease  is  invited  to  the  low- 
er limbs  by  prolonged  effort  on  the  legs.  Exhausting  diseases,  the 
poisons  of  lead  and  syphilis,  and  certain  dyscrasise,  seem  to  exert  an 
influence  in  developing  the  disease.  Exposure  to  cold  and  mechanical 
injuries  have  apparently  given  rise  to  progressive  atrophy. 

Pathological  Anatomy. — The  morbid  alterations  are  of  two  groups 
— spinal  and  muscular.  The  changes  in  the  spinal  cord  are  similar  to 
those  which  take  place  in  infantile  paralysis,  namely  :  atrophy  and  de- 
generation of  the  anterior  columns,  wasting  and  disappearance  of  the 
multipolar  ganglion-cells,  of  the  anterior  horns,  hyperplasia  of  the  neu- 
roglia, corpora  amylacea,  granule-cells  and  fat-corpuscles.  The  anterior 
roots  are  similarly  affected — are  wasted,  atrophied,  and  degenerafed. 
In  one  third  of  the  reported  cases  in  which  the  cord  was  examined,  no 
changes  were  found  of  any  kind.  The  alterations  in  the  muscles  have 
been  most  elaborately  studied  by  Friedreich,*  who  holds  to  the  mus- 
cular ox-igin  of  the  disease.  He  asserts  that  the  initial  change  consists 
in  an  inflammation  with  hyperplasia  of  the  interstitial  connective  tissue 
uniting  the  primitive  bundles.  Morbid  changes  occur  in  the  primitive 
bundles  :  proliferation  of  the  nuclei  and  multiplication  of  the  muscular 
coi'puscles.  Wasting  of  the  muscular  substance  goes  on,  pari  passu, 
with  the  increase  of  the  connective  tissue,  and  fatty  degeneration  con- 
tributes to  it.  The  final  result  is,  that  the  muscle  is  converted  into  a 
mere  fibrous  band  with  numerous  fat-cells,  the  development  of  this 
latter  material  taking  place  outside  of  the  muscular  elements  and  in  the 
newly  formed  connective  tissue.  The  theory  of  Friedreich,  which  he 
maintains  with  remarkable  skill  and  learning,  is  that  the  disease  begins 
in  the  muscles,  the  intramuscular  nerves  are  next  affected,  and  an  as- 
cending neuritis  conveys  the  morbid  process  to  the  spinal  cord,  which 
becomes  in  turn  diseased.  The  other  view  is,  that  the  changes  in  the 
muscles  are  secondary  to  the  morbid  process  in  the  spinal  cord,  espe- 
cially in  the  multipolar  ganglion-cells  of  the  cornua.f 

Symptoms. — According  to  Friedreich's  statistics,  of  one  hundred  and 
forty-six  cases,  there  were  one  hundred  and  eleven  instances  of  the  dis- 

*"Ueber  progressive  Muskclatrophie,"  etc.,  von  Dr.  N.  Friedreich,  Berlin,  ISYS, 
cap,  ii,  p.  46. 

f  Charcot  and  Joffroy,  "  Archives  de  Physiologic,"  vols,  ii  and  iii,  op.  cit.  A.  Hayem, 
ibid.  See  also,  as  explanatory  of  spinal  affections  consecutive  to  nerve-injuries,  A.  Vul- 
pian,  ibid.,  p.  221. 

37 


578  DISEASES   OF   THE   NERVOUS   SYSTEil. 

ease  beginning  in  the  right  upper  extremity,  twenty-seven  in  the  lower, 
and  eight  in  the  lumbar  muscles.  Sometimes  the  tongue,  sometimes 
the  palate  muscles,  an  example  of  which  the  author  has  seen,  are  first 
affected.  The  first  dorsal  interosseus  is  usually  the  first  muscle  at- 
tacked in  the  upper  extremity,  then  the  muscles  of  the  thenar  and  hy- 
pothenar  eminence,  the  deltoid,  etc.  Sometimes  the  pectoralis  major 
and  serratus  magnus  are  the  first  to  undergo  atrophy.  In  children  the 
lumbar  muscles  are  usually  the  first  to  atrophy,  the  degeneration  taking 
the  form  of  pseudo-hypertrophic.  The  loss  of  volume  which  the  mus- 
cles undergo  is  not  always  a  measure  of  the  real  degeneration,  since  a 
very  considerable  hyperplasia  of  the  fatty  tissue  sometimes  takes  place, 
with  the  effect  to  increase  the  apparent  size.  The  next  s}Tnptom  is 
fibrillary  contraction  :  the  muscle  undergoing  atrophy  so  long  as  it 
remains,  is  agitated  by  fine  tremors,  which  consist  in  waves  or  oscilla- 
tions of  movement  of  the  muscular  fibrillae.  If,  now,  the  muscles  of 
the  diseased  hand  are  tested  by  the  dynamometer,  they  will  be  found 
extremely  weak  as  compared  with  the  sound  hand.  The  hand  also 
becomes  greatly  deformed,  rigid,  and  claw-like,  presenting  the  appear- 
ance of  a  bird's  talons.  The  electro-contractility  is  preserved  so  long 
as  muscular  fibers  remain  to  be  stimulated,  but  the  reaction  to  the  gal- 
vanic persists  for  some  time  after  the  faradic  excitability  has  disap- 
peared. In  most  patients  a  good  deal  of  pain  is  experienced  in  the 
muscles  about  to  be  affected  and  during  the  process  of  wasting,  but 
the  sensibility  to  jsain  and  to  temperature  diminishes  to  below  normal 
in  the  last  stages.  The  temperature  of  the  wasted  parts  is  also  reduced 
several  degrees,  and  they  are  cold  to  the  touch  ;  and  the  integument 
appears  normal  or  pale,  or  blue,  and  cyanosed.  The  perspiration  is 
usually  increased  in  the  affected  member  or  part,  and  sometimes  gen- 
erally. Changes  in  the  joints,  comparable  to  those  which  take  place 
in  locomotor  ataxia  and  other  spinal  diseases,  are  also  observed  in  pro- 
gressive muscular  atrophy.*  Changes  in  the  pupil  and  other  oculo- 
motor phenomena  occur  when  progressive  muscular  atrophy  is  asso- 
ciated with  glosso-labio-pharyngeal  paralysis.  This  disease  may  be 
accompanied  with  fever  during  the  first  weeks  or  months,  often  asso- 
ciated with  the  joint-lesions.  How  far  this  is  accidental  or  a  necessary 
part  of  progressive  muscular  atroj)hy  does  not  appear  to  be  well  under- 
stood. 

Course,  Duration,  and  Termination. — The  course  of  this  disease  is 
extremely  protracted  in  many  cases.  The  manner  of  spread  of  the 
myopathic  process  is  not  in  accordance  with  a  uniform  plan.  It  some- 
times extends  by  contiguity  of  tissue,  sometimes  leaps  over  groups  of 
muscles  to  attack  distant  muscles.  The  extension  is  limited  by  the 
larger  joints.     Beginning  in  the  hand,  an  extension  to  the  arm  does 

*  On  this  point  consult  Weir  Mitchell's  "  Spinal  Arthropathies.''  in  "  Amcricaji  Journal 
of  the  Medical  Sciences,"  April,  1875,  p.  339. 


PROGRESSIVE  MUSCULAR  ATROPHY.  579 

not  take  place  ;  some  of  the  extensors  of  the  forearm  undergoing  atro- 
phy, the  muscles  of  the  arm  are  not  attacked  ;  the  deltoid  and  arm 
muscles  affected,  the  elbow-joint  is  not  passed  ;  similarly  in  atrophy  of 
the  leg-muscles,  the  knee-joint  seems  to  prevent  extension  to  the  thigh. 
Some  muscles  are  never  affected  ;  those  of  the  head  are  not  often  ;  and, 
when  the  tongue  and  lip  muscles  and  the  laryngeal  muscles  are  affected, 
the  disease  is  complicated  with  glosso-labio-laryngeal  paralysis.  The 
diaphragm  and  the  respiratory  muscles  and  the  accessory  muscles  of 
respiration  are  finally  invaded.  Death  then  ensues  by  hypostatic  con- 
gestion and  oedema  of  the  lungs.  When  the  larynx  is  invaded,  the 
voice  is  lost,  and  there  is  difficulty  of  breathing  from  cessation  of  the 
laryngeal  movements.  The  muscles  of  the  ear  may  also  be  invaded, 
and  impaired  hearing  result.  Friedreich  gives  a  remarkable  example, 
pictorially  represented,  of  a  man  all  of  whose  voluntary  muscles  are 
wasted,  and  who  seems  to  retain  alone  the  power  of  breathing.  The 
march  to  this  end.  is  exceedingly  slow,  unless,  as  is  not  unfrequently 
the  case,  the  morbid  process  involves  the  anterior  cornua  of  the  me- 
dulla oblongata,  the  effects  of  which  have  already  been  described.  At 
first  no  trouble  is  produced  by  the  wasting  of  the  muscles  of  the 
extremities  ;  the  general  health  does  not  suffer  ;  the  powers  of  body 
and  mind  are  otherwise  adequate  to  their  work.  Sometimes  the  dis- 
ease is  arrested,  and  remains  stationary  for  years.  A  few  cases  are 
terminated  by  bed-sores  ;  many  by  intercurrent  maladies,  of  which 
pulmonary  tuberculosis  is  the  chief. 

Diagnosis. — A  fully  formed  case  can  never  present  any  difficulty  in 
this  respect,  but  at  the  initial  period  there  may  be  doubt  whether  the 
wasting  is  due  to  local  injury,  injury  of  the  nerve-trunk,  or  the  result 
of  rheumatism.  The  distinction  rests  on  the  pains,  the  fibrillary  trem- 
bling, and  the  absence  of  any  local  cause  to  account  for  the  atrophy. 

Treatment. — Nothing  has  ever  been  accomplished  by  the  use  of 
internal  medicines.  The  author  has  apparently  effected  great  improve- 
ment in  a  case,  confined  as  yet  to  the  left  upper  extremity,  by  the 
injection  of  glycerine  solution  into  the  wasting  muscles.  The  strength 
of  the  solution  is  one  third  glycerine,  and  it  is  injected  three  times  a 
week.  The  two  remedies  of  unquestionable  utility  are  galvanism  and 
massage.  The  author  has  had  good  results  from  galvanism,  and  he 
can  not  share  the  despondency  of  authors  generally  in  regard  to  its 
utility.  Erb  reports  favorably  as  to  the  good  effects  of  the  galvanic 
current.  Strong  currents  must  be  used  to  excite  vigorous  contractions 
for  a  brief  period — two  minutes.  A  descending  current  should  also  be 
applied  to  the  whole  length  of  the  spine,  daily,  for  a  minute  or  two. 
Massage,  using  with  friction  a  fat,  preferably  lard,  is  also  highly  ser- 
viceable. This  should  consist  of  friction,  kneading,  and  tapping  the 
muscles.  Hot  douches  to  the  spine  and  the  rubbing  wet  pack  for  the 
affected  members  are  also  to  be  highly  commended. 


580  DISEASES  OF  THE  NERVOUS  SYSTEM. 

PSEUDO-HTPERTROPHIO  PROGRESSIVE  MUSCULAR  ATROPHY. 

Pathogeny  and  Symptoms. — This  disease  differs  from  progressive 
muscular  atrophy,  in  the  remarkable  fact  that  the  atrophied  muscles 
increase  in  size,  and  are  apparently  hypertrophied,  because  of  an  hyper- 
plasia of  the  connective  and  fatty  tissue.  The  anatomical  change  con- 
sists, in  brief,  in  a  proliferation  of  the  connective  tissue  between  the 
fibrilla  (Friedreich)  and  the  adventitia  of  the  small  vessels.  The 
newly  formed  connective  tissue  is  remarkable  for  the  number  of  its 
cells  and  nuclei,  which  are  transformed  into  fat-cells.  As  the  connec- 
tive tissue  develops  the  muscular  elements  disappear,  or  at  least  only 
in  part  remain,  much  altered,  and  thinner.  Now  and  then  are  encoun- 
tered some  muscular  fibers  which  have  undergone  hypertrophy.  The 
muscular  elements  are  also  invaded  by  an  irritative  process,  become 
granular  and  degenerate,  so  that  the  atrophy  is  not  wholly  a  simple 
atrophy  from  overgrowth  of  the  connective  tissue.  When  the  process 
is  complete  the  muscles  present  a  grayish  or  yellowish-white  appear- 
ance, and  can  hardly  be  distinguished  from  the  adjacent  fatty  and  con- 
nective tissue. 

This  disease  occurs  almost  wholly  in  childhood,  and  before  ten 
years  of  age.  In  eighty  cases,  it  began  from  the  first  to  the  fifth  year 
in  forty-five  ;  from  the  sixth  to  the  tenth,  twenty-two  times  ;  from  the 
eleventh  to  the  sixteenth,  eight  times  ;  and  in  five  cases  it  occurred 
from  the  twenty-second  to  the  forty-third  year  (Erb).  Hereditary  in- 
fluence plays  a  very  important  part  in  the  development  of  the  disease; 
other  causes  have  been  assigned,  and  probably  with  little  reason,  for 
all  the  facts  go  to  prove  the  existence  of  a  peculiar  neurodiathesis. 

The  morbid  process  begins  in  the  lower  limbs — chiefly  in  the  legs, 
although  it  may  begin  in  the  thighs.  Before  the  hypertrophic  en- 
largement manifests  itself,  muscular  weakness  has  occurred  ;  fatigue  is 
quickly  experienced  ;  the  legs  trip  easily  and  give  way  ;  the  gait  is 
awkward.  After  a  time  a  child  thus  affected  is  not  able  to  rise,  when 
down,  unless  aided,  and  can  not  walk  unless  steadied  ;  the  gait  assumes 
a  straddling  manner,  somewhat  like  that  of  a  duck,  and  when  the 
thigh-muscles  are  affected  he  can  not  rise  unless  he  supports  his  thighs 
by  his  hands,  and  in  sitting  down  can  not  control  the  act,  but  plumps 
down  suddenly.  When  recumbent,  the  legs  are  wide  apart,  the  soles 
of  the  feet  turned  toward  each  other,  the  heels  drawn  up,  and  the  knee 
and  hip  joints  flexed.  All  the  movements  of  the  foot  are  imperfectly 
executed,  except  flexing  the  toes  ;  the  movements  of  the  thigh  are 
equally  imperfect,  except  mere  flexion  of  the  knee.  The  position  in 
standing  is  very  characteristic  :  the  lumbar  portion  of  the  spine  is 
greatly  incuiwed  (lordosis),  the  dorsal  portion  bent  outward  (gib- 
bosity). The  diminution  in  power  offers  a  remarkable  contrast  to  the 
enormous  bulk  of  the  affected  members.     If  the  disease  attacks  the 


MULTIPLE   SCLEROSIS   OF   THE   BRAIN   AND   CORD.  581 

upper  extremity,  it  takes  the  form  of  progressive  muscular  atrophy, 
and  the  two  may  exist  together.  Before  the  muscular  tissue  has  disap- 
peared, the  same  fibrillary  twitchings  occur  as  in  the  other  form  of 
the  disease.  The  electro-contractility  declines  progressively  with  the 
diminution  of  the  muscular  elements,  and  in  this  disease  the  more  de- 
cidedly because  of  the  great  collection  of  fatty  and  fibroid  tissue  over- 
lying the  muscular  elements.  There  is  more  or  less  pain  experienced 
by  these  patients,  in  the  back,  and  through  the  parts  to  become  affect- 
ed. The  temperature  declines  several  degrees  in  the  hypertrophied 
and  atrophied  parts.  The  termination  of  these  cases  has  been  by 
some  intercurrent  disease,  usually  of  the  respiratory  organs. 


SOME    DISEASES  AFFECTING    THE    BRAIN  AND 
SPINAL  CORD. 


MULTIPLE    SCLEROSIS    OF    THE    BRAIN    AND    CORD. 

Definition. — By  the  term  multiple  sclerosis  of  the  brain  and  cord  is 
meant  a  disease  characterized  by  the  formation  of  isolated  patches  or 
nodules  of  sclerotic  tissue  in  the  brain,  pons,  medulla,  cerebellum,  and 
spinal  cord.  It  is  sometimes  treated  of  as  cerebral  sclerosis  and  spinal 
sclerosis,  but  it  becomes  more  and  more  apparent  that  neither  organ 
is  separately  affected.  By  Charcot*  it  is  entitled  "disseminated 
sclerosis." 

Causes. — In  this  disease  both  sexes  are  about  equally  affected,  and 
it  occurs  from  youth  to  middle  age,  becoming  very  rare  after  forty -five 
and  before  ten.  The  most  powerful  predisposing  cause  is  heredity. 
Exposure  to  cold  and  fatigue,  living  in  damp  habitations,  and  sudden 
exposure  of  the  body  to  cold  and  dampness  when  in  a  warm  and  per- 
spiring state,  are  alleged  to  be  causes,  but  doubts  may  well  exist  as  to 
their  influence  unless  a  predisposition  exist.  Powerful  and  prolonged 
moral  emotion,  chagrin,  anxiety,  and  other  depressing  moral  causes, 
may  favor  the  development  of  this  affection.  It  occurs  in  th«  conva- 
lescence from  acute  infectious  diseases. 

Pathological  Anatomy. — The  disease  in  the  brain  and  cord,  to  the 
naked  eye,  appear  as  glistening  nodules  underneath  the  pia.  They 
are  distinctly  circumscribed,  grayish  patches,  raised  a  little  above  the 

*  "  Diseases  of  the  Nervous  System,"  "  Sydenham  Society  Translation,"  lecture 
vi,  p.  157. 


582  DISEASES  OF  THE  NERVOUS  SYSTEM. 

level  of  the  cord  sometimes,  or  depressed  below,  or  on  a  level  with  the 
general  surface,  but  always  perfectly  defined  from  the  adjacent  tissue. 
The  patches  are  somewhat  gelatinous  and  translucent,  and  marked  by 
fine  white  lines,  round  or  elliptical  or  irregular  in  shape,  somewhat 
closely  arranged,  often  confluent ;  dense,  tough,  almost  cartilaginous 
in  hardness  ;  on  section,  rather  glistening.  The  nodules  vary  greatly 
in  size,  from  minute,  microscopic  objects  up  to  the  size  of  a  walnut ; 
in  the  brain  they  enlarge  laterally  ;  in  the  cord,  in  its  long  diameter. 
They  vary  greatly  in  number  as  in  size,  and  are  distributed  widely 
through  the  brain  and  cord.  In  the  brain  they  are  found  not  in  the 
gray  but  the  white  matter — in  the  white  matter  of  the  hemispheres, 
ventricles,  optic  thalamus,  corpus  striatum,  peduncles,  pons,  cerebel- 
lum ;  in  the  cord,  the  nodules  are  found  both  in  the  gray  and  white 
matter  and  in  the  columns.  The  deposits  occur  in  the  nerve-roots  and 
the  nerve- trunks  just  as  in  the  nerve-centers.  The  nodules  them- 
selves are  composed  of  the  neuroglia,  much  hypertrophied,  a  newly 
formed  fibrillated  connective  tissue,  remains  of  the  nerve-elements, 
fat-  and  granule-cells,  and  corpora  amylacea.  In  the  nerve-fibers, 
the  medullary  sheath  is  first  encroached  on  by  the  hyperplasia  of  the 
neuroglia,  disappears  by  absorption,  leaving  the  axis-cylinder,  which 
in  turn  undergoes  the  sclerotic  change,  then  disappears,  so  that  ulti- 
mately nothing  remains  but  the  newly  formed  fibrous  tissue  contain- 
ing numbers  of  so-called  "  spider-cells,"  free  nuclei,  corpora  amylacea, 
and  fat.  Similar  changes  occur  in  the  walls  of  the  vessels,  beginning 
in  the  adventitia  and  in  the  perivascular  lymph-spaces.  Ultimately 
the  adventitia  is  closely  united  to  the  surrounding  connective  tissue, 
the  other  tunics  are  invaded  by  the  hypertrophied  connective  tissue, 
nuclei  form  in  great  numbers,  fatty  degeneration  occurs,  the  fat-ele- 
ments crowding  the  perivascular  lymph-spaces,  and  encroaching  on 
the  lumen  of  the  vessels. 

Symptoms. — There  are  three  forms  usually  described  :  the  cerebral, 
the  spinal,  and  the  cerebro-spinal.  But  the  description  of  this  disease 
was  purposely  postponed  to  this  point,  as  the  spinal  and  cerebral  forms 
rarely,  if  ever,  exist  separately,  but  the  disease  is  cerebro-spinal  scle- 
rosis, in  which,  it  is  true,  there  may  be  a  predominance  of  the  cerebral 
or  of  the  spinal  symptoms  in  different  cases,  but  in  all  the  traces  of 
both  are  discernible. 

There  are  two  modes  of  onset — a  gradual  and  insidious  mode,  and 
a  sudden  and  severe  mode.  When  it  begins  slowly  the  symptoms 
may  be  chiefly  cerebral  or  chiefly  spinal  :  in  the  former,  headache, 
vertigo,  convulsions,  or  an  attack  of  an  apoplectiform  variety,  disor- 
dered and  staggering  gait,  tremors  in  certain  limbs  or  groups  of  mus- 
cles, impairment  of  special  senses — of  sight,  of  taste,  of  hearing,  dou- 
ble vision,  etc.;  imperfect  speech,  and  mental  disorders  of  various 
kinds  ;  in  the  latter  (spinal  form)  there  will  be  weakness  and  uncer- 


MULTirLE   SCLEROSIS   OF   THE   BRAIN  AXD   CORD.  583 

tainty  of  gait,  ataxic  disorders,  numbness,  tingling  and  pains  in  the 
extremities,  incoordinate  movements  in  writing,  trembling,  and  severe 
attacks  of  gastralgia.  This  disease,  as  Charcot  happily  said,  "  is,  in 
fact,  an  eminently  polymorphic  affection."  *  In  the  sphere  of  the 
sensory  nervous  system  there  are  pains  of  various  kinds,  according  to 
the  position  of  the  sclerotic  nodules  ;  pains  in  the  face  in  the  distribu- 
.tion  of  the  fifth  nerve,  in  the  arms,  and  in  the  lower  limbs,  of  an 
acute,  lancinating  character,  with  more  diffused  pains  with  a  sense  of 
pressure,  constricting  or  girdle  pain  around  the  abdomen  at  different 
heights,  with  pains  in  the  back  and  hips.  Instead  of  pain,  there  is 
at  a  more  advanced  stage  loss  of  sensation  in  various  parts,  or  anaes- 
thesia and  analgesia.  The  sense  of  the  position  of  members  and  of 
weight  and  resistance  is  also  disordered  or  lost.  There  may  be  an 
entire  absence  of  these  sensations,  and  the  appreciation  of  touch  and 
pain  continue  normal.  The  disturbances  in  the  motor  sphere  are  more 
constant ;  first,  motor  weakness  or  paresis,  which  attacks  one  leg,  then 
the  other,  and  after  a  time  the  arms,  or  the  order  may  be  reversed  ; 
difficulty  of  locomotion,  due  not  only  to  paralysis  but  to  tonic  con- 
traction— the  contraction  of  extension — which  imparts  to  the  gait  a 
shuffing,  dog-trot,  or  titubating  character.  The  tonic  contraction  of 
extension  passes  into  permanent  contractures  and  rigidity.  In  many 
cases  in  which  sclerosed  nodules  are  largely  deposited  in  the  posterior 
columns  the  gait  is  incoordinate,  and  the  usual  phenomena  of  ataxia 
(reeling  with  the  eyes  closed,  the  peculiar  gait)  are  present.  Similar 
changes  occur  in  the  upper  extremity,  but  the  contractures  and  paraly- 
ses are  usually  hardly  so  pronounced  as  in  the  lower  extremities.  A 
A^ery  characteristic  symptom  is  tremor,  a  shaking  tremor,  which  occurs 
only  during  voluntary  movement,  and  ceases  when  the  parts  are  at 
rest.  In  the  words  of  M.  Charcot,  "  the  tremor  manifests  itself  on  the 
occasion  of  intentional  movements  of  soine  extent ;  it  ceases  to  exist 
xohen  the  muscles  are  abandoned  to  complete  repose^''  Exceptional 
cases  are  encountered  in  which  tremor  is  not  present.  It  may  have 
been  present  and  then  disappeared  ;  it  ceases  when  permanent  con- 
tractions occur,  so  that  the  case  can  not  be  regarded  as  exceptional  if 
the  tremor  is  found  on  inquiry  to  have  been  present  at  some  previous 
time  and  is  now  absent.  The  more  powerfully  the  will  is  directed  to 
the  act,  the  more  considerable  and  extensive  the  trembling.  In  con- 
veying a  glass  of  water  to  the  mouth,  the  water  is  spilled  and  the  glass 
rattles  against  the  teeth.  In  any  muscular  act  to  which  the  attention 
is  strongly  attracted,  not  only  the  member  acting,  but  the  head,  neck, 
and  body  are  thrown  into  violent  trembling.  The  reflexes  are  vari- 
ously affected,  and  may  be  diminished  or  absent,  but  are  often  greatly 
increased,  especially  the  tendon  reflexes.     Vesical,  sexual,  and  rectal 

*  Supra^  p.  183. 


584  DISEASES  OF   THE  NERVOUS  SYSTEM. 

disturbances  only  appear  toward  the  end,  when  incontinence,  impo- 
tence, and  constipation  will  come  on.  While  these  symptoms  from 
the  spinal  lesions  are  developing,  characteristic  cerebral  phenomena 
also  are  occurring.  The  psychical  functions  are  disordered.  At  first, 
changes  of  disposition  are  noticed,  the  emotional  centers  becoming 
easily  excited,  and  laughing  and  weeping  occurring  with  equal  readi- 
ness ;  irritability  of  temper  and  unexpected  gusts  of  anger  are  com- 
mon. Memory  is  early  impaired,  and  reason,  judgment,  and  the 
power  to  acquire  knowledge  are  much  weakened.  Presently  distinct 
forms  of  mental  derangement  make  their  appearance,  as  melancholia, 
mania  with  exaltation,  and  finally  dementia.  During  the  course  of 
development  of  the  psychical  symptoms,  vertigo,  severe  headache,  and 
attacks  of  obstinate  wakefulness  appear,  and  there  are  also  now  and 
then  apoplectiform  attacks,  followed  by  hemiplegia.  Peculiar  altera- 
tions occur  in  the  speech  and  voice.  The  speech  has  the  slow,  jerking 
movement  as  in  scanning,  and  becomes  less  and  less  distinct.  The 
tongue  and  lips  and  the  muscles  of  the  palate  and  pharynx  become 
paretic,  and  hence  mastication  and  swallowing  are  difiicult.  The  ocu- 
lar muscles  being  similarly  aifected,  there  are  diplopia,  or  double  vis- 
ion, nystagmus,  and  amblyopia,  proceeding  ultimately  to  amaurosis. 

Course,  Duration,  and  Termination. — Not  all  cases  pursue  the  typi- 
cal course  just  described.  The  cerebral  symptoms  may  be  in  excess, 
and  the  spinal  less  pronounced  (cerebral  sclerosis)  and  vice  versa  (spinal 
sclerosis).  As  Erb  has  well  said,  "the  correctness  of  this  division  has 
not,  however,  been  demonstrated  with  satisfactory  clearness."  Char- 
cot has  divided  the  disease  into  three  parts  (p.  210)  :  the  first  extend- 
ing from  the  inception  to  the  permanent  contractures — a  period  of 
very  variable  duration,  but  lasting  from  two  to  six  years  ;  the  second 
period,  in  which  the  motor  functions  are  almost  abolished,  the  mind 
disordered,  but  the  nutrition  continues  good,  in  which  the  individual 
is  reduced  to  a  merely  vegetative  existence,  continues  not  less  than 
four  and  often  more  than  six  years  ;  the  third  period  is  comparatively 
brief,  in  which  nutrition  fails,  digestion  becomes  disordered,  swallow- 
ing increasingly  difficult,  cystitis  arises  from  paralysis  of  the  bladder, 
bed-sores  form,  respiration  and  circulation  become  irregular  and  dis- 
ordered, by  reason  of  extension  of  the  sclerosis  to  the  medulla,  apo- 
plectic attacks  occur,  and  not  unfrequently  some  intercurrent  disease 
appears.  The  whole  duration  of  the  disease  varies  from  one  or  two 
years  to  twenty,  but  the  average  is  five  to  ten  years.  The  termination 
may  be  by  exhaustion  or  by  apoplexy,  but  usually  some  pulmonary 
disease  ends  life.  The  termination  by  death  is  the  only  one  known. 
Sometimes  remissions  occur  that  are  very  illusory. 

Diagnosis. — The  fully  developed  disease  is  so  remarkable,  by  reason 
of  the  multiplicity  of  the  symptoms,  that  a  diagnosis  is  made  without 
difficulty.    But  in  the  partial  cases  there  may  be  much  difficulty.    Cere- 


DEMENTIA  PARALYTICA.  585 

bro-spinal  sclerosis  is  often  confounded  with  paralysis  agitans.  The 
former  occurs  in  youth  and  early  manhood,  the  latter  in  old  age  ;  the 
former  is  accompanied  by  tremors  that  do  not  occur  when  the  patient 
is  at  rest,  and  increase  by  volitional  effort ;  the  latter  by  tremors  that 
continue  during  rest,  and  that  are  lessened  by  an  effort  of  the  will. 
In  the  former,  paresis  or  paralysis  precedes  tremor  ;  in  the  latter,  suc- 
ceeds, and  long  after.  In  the  former,  peculiar  defects  of  speech,  of 
vision,  of  motility,  etc.,  occur  ;  in  the  latter  not.  Cerebro-spinal  scle- 
rosis may  be  confounded  with  locomotor  ataxia,  as  in  both  there  are 
ataxic  disorders.  In  the  former,  there  are  mental  disorders,  paralysis, 
contractures,  tremor,  troubles  of  speech,  and  preserved  and  increased 
tendon  reflexes  ;  in  the  latter,  none  of  these,  and  ataxia  without  paraly- 
ses or  contractures,  pains,  peculiar  sexual  disorders,  and  no  tendon 
reflexes. 

Treatment. — Several  remedies  have  appeared  to  act  beneficially, 
although  no  cures  have  occurred.  "  Marked  improvement  set  in  under 
the  use  of  subcutaneous  injections  of  arsenic,"  says  Erb,  in  one  case. 
The  galvanic  current  has  appeared  to  benefit  in  a  few  instances.  In 
other  cases  good  results,  if  temporary,  have  been  produced  by  nitrate 
of  silver.  Hammond  thinks  the  chloride  of  barium  does  good.  The 
most  promising  treatment  is  the  combined  use  of  galvanism,  cold 
hydrotherapeutic  applications,  carefully  made,  cod-liver  oil  internally, 
and  probably  the  nitrate  of  silver.  The  author  begs  to  suggest  the 
necessity  for  caution  in  the  use  of  silver,  lest  staining  of  the  tissues 
occur. 

DEMENTIA  PARALYTICA— PROGRESSIVE   GENERAL   PARALY- 
SIS. 

Definition. — By  dementia  paralytica  is  meant  an  atrophic  change 
in  the  brain  characterized  by  a  peculiar  form  of  mental  derangement, 
associated  with  general  paralysis. 

Causes. — The  cases  largely  preponderate  in  the  male  sex,  the  dis- 
proportion being  nearly  four  to  one.  The  most  active  and  vigorous 
period  in  life — from  twenty-five  to  forty-five — is  the  period  for  the 
appearance  of  this  disease.  Heredity  seems  to  be  an  important  cause^ 
but  the  data  do  not  exist  for  an  exact  statement.  Excesses — the  com- 
bined effect  of  overwork,  alcoholic  abuse,  and  venereal  indulgence — 
are  the  most  influential  of  all  factors  operating  to  produce  the  disease. 

Pathological  Anatomy. — A  diminution  in  the  weight  and  volume 
of  the  brain,  due  to  an  atrophy  of  its  gray  and  white  substance,  is  the 
characteristic  alteration  in  this  disease.  The  pia  mater  is  (edematous, 
generally,  or  in  the  sulci,  and  a  good  deal  of  water  is  found  between 
the  parietal  and  occipital  lobes  ;  the  ventricles,  especially  the  cornua, 
are  dilated,  the  ependyma  thickened  and  roughened  by  granular  depo- 
sition ;  the  convolutions  are  shrunken,  particularly  those  of  the  poste- 


586  DISEASES  OF  THE  XERVOTJS  SYSTEM. 

rior  lobes,  and  the  white  and  gray  matter  thinned  and  atrophic.  The 
pia  mater  is  greatly  changed  in  structure,  especially  in  the  neighborhood 
of  the  vessels,  and  thickened  by  spots  and  patches  of  exudation  of  a 
yellowish  color,  and  is  readily  stripped  from  the  brain-substance.  The 
dura  mater  is  also  much  altered,  closely  united  to  the  skull,  thickened 
by  exudations,  and  sometimes  covered  by  a  sanguineous  extravasation. 
A  peculiar  change  takes  place  in  the  vessels,  of  which  the  initial  alter- 
ation is  an  increase  of  the  nuclei  in  their  tunics,  and  filling  of  the 
perivascular  lymph-spaces  with  white  and  red  corpuscles.  The  walls 
of  the  vessels  become  fatty  or  undergo  the  colloid  degeneration.  The 
ganglion-cells  of  the  gray  matter  pass  through  atrophic  changes,  re- 
sulting in  their  final  destruction.  The  membranes  of  the  spinal  cord 
undergo  similar  changes  to  the  cerebral,  but  less  frequently.  Impor- 
tant alterations  take  place  in  the  spinal  cord  ;  gelatiniform  degenera- 
tion, with  entire  disappearance  of  the  proper  anatomical  elements,  is 
the  final  result.  The  posterior  columns  are  altered  throughout  their 
whole  extent  in  the  dorsal  and  lumbar  portion,  but  in  the  cervical 
the  change  is  chiefly  in  Goll's  columns.  Another  kind  of  change 
which  takes  place  in  the  postero-lateral  columns  is  a  granular  mye- 
litis, followed  by  hyperplasia  of  the  connective  tissue.  Both  kinds  of 
change  may  exist  together.  The  granular  myelitis  is  not  limited  to 
the  cord  proper,  but  extends  to  the  medulla,  pons,  and  crura  cerebri. 
The  posterior  roots  are  affected  with  the  posterior  columns,  but  the 
peripheral  nerves  are  seldom  diseased. 

Symptoms. — The  symptoms  of  this  disease  are  naturally  divisible 
into  two  groups — mental  and  motor  derangements.  A  correct  appre- 
ciation of  the  mental  phenomena  in  these  cases  is  of  the  highest  im- 
portance, owing  to  the  serious  complications  often  arising  out  of  the 
conduct  of  these  subjects.  The  motor  disturbances  may  precede,  but 
they  more  usually  follow,  the  first  evidences  of  mental  aberration. 
Changes  in  the  character  and  disposition  are  manifest ;  irritability  and 
a  quai-relsome  disposition,  quite  at  variance  -with  the  previous  character, 
it  may  be,  become  manifest.  Headache,  which  is  worse  in  the  morn- 
ing, and  transient  vertigo  are  experienced.  It  is  observed  that  they 
fail  in  memory,  especially  of  recent  events  ;  they  are  absent-minded 
and  talk  to  themselves.  Some  trembling  of  the  lips  may  be  seen,  of  the 
muscles  of  the  face  and  of  the  tongue  ;  the  speech,  becomes  thick  and 
rather  guttural  and  is  hesitating,  and  at  the  same  time  the  voice  is 
changed,  it  is  nasal  and  has  assumed  a  different  quality,  the  tenor 
voice  becoming  bass.  Owing  to  the  paresis  and  fibrillary  trembling 
of  the  muscles  of  the  tongue,  and  paresis  of  the  muscles  of  the  lips, 
the  labials  are  pronounced  with  difficulty  or  slurred  over.  They  early 
have  expansive  ideas  and  most  deluded  notions  of  what  they  can  ac- 
complish. Before  their  mental  unsoundness  is  patent,  they  make  pur- 
chases, or  engage  in  ruinous  enterprises,  always  on  a  large  scale,  and 


DEMENTIA   PARALYTICA.  587 

they  often  exhibit  a  marvelous  ingenuity  in  accounting  for  their  acts. 
Hence  the  frequent  litigation  growing  out  of  the  acts  of  such  paralyt- 
ics before  their  real  condition  is  known.  After  a  time  their  ideas  be- 
come so  extravagant  that  the  least  informed  can  understand  their  state. 
Such  a  man  has  written  an  immortal  work,  or  made  a  great  invention, 
will  build  a  house  many  miles  high,  will  run  a  railroad  to  the  moon, 
possesses  countless  wealth,  is  a  king,  has  astonishing  personal  prowess, 
has  the  strength  of  a  thousand  men,  etc.  So  quick  is  he  to  forget  his 
statements  that,  if  exposed  in  an  absurdity,  he  immediately  reaffirms  it 
in  a  still  stronger  form.  He  is  therefore  perfectly  happy  in  the  midst 
of  his  delusions  of  personal  importance.  Meanwhile  he  has  become 
indifferent  to  all  the  obligations  and  duties  of  life,  ceases  to  have  any 
affection  for  the  members  of  his  family,  or  cares  for  one  only,  pays  no 
attention  to  his  affairs,  and  steals,  without  a  thought  of  the  offense. 
Not  all  cases  present  the  evidence  of  exaltation  of  ideas  and  happi- 
ness from  a  false  conception  of  personal  importance  and  well-being. 
Some  are  dejected  and  melancholy,  but  the  ideas  of  depression  have 
corresponding  vastness,  and  their  misfortunes  are  the  greatest  the 
world  has  ever  seen.  During  the  course  of  development  of  the  men- 
tal symj^toms,  some  of  these  subjects  are  given  to  paroxysms  of  rage 
as  blind  and  ungovernable  as  those  of  an  epileptic.  Enraged  by  the 
least  opposition,  or  excited  by  some  trivial  incident,  they  will  commit 
a  murderous  assault  on  their  best  friends,  and  this,  too,  stealthily  and 
without  warning.  During  this  state  there  is  wild  excitement  like 
acute  mania.  This  condition  of  excitement  may  persist  until  death 
by  maniacal  exhaustion,  or  it  may  pass  into  the  condition  of  dementia. 
As  these  attacks  of  excitement  are  accompanied  by  elevated  tempera- 
ture, it  is  probable  they  are  induced  by  chronic  meningitis,  traces  of 
which  are  always  seen  in  the  anatomical  changes.  The  ideas  of  exal- 
tation and  of  melancholy  often  are  present  in  the  same  case,  and  alter- 
nate, the  patient  passing  quickly  from  one  to  the  other.  Delusions 
are  not  always  present.  There  may  be  a  gradual  and  progressive  fail- 
ure of  intelligence  to  dementia,  without  there  being  any  delusion, 
unless  the  expansive  notions,  which  are  apt  to  appear  some  time,  are 
so  regarded.  A  very  characteristic  mental  state  is  the  unconscious- 
ness of  weakness  and  of  disease  exhibited  by  these  subjects,  unless, 
as  may  happen  during  a  remission,  the  patient  recovers  sufficient  mem- 
ory and  judgment  to  appreciate  his  changed  state.  During  the  height 
of  the  symptoms,  although  paralyzed,  he  has  the  strength  of  a  giant, 
and,  though  suffering  from  ailments  which  in  the  ordinary  state  of  the 
mind  cause  great  distress,  he  experiences  nothing  but  an  extravagant 
sense  of  well-being.  In  the  motor  sphere  very  important  symptoms 
arise.  Disorders  of  coordination  begin  in  the  inferior  extremities — 
an  ataxic  gait,  reeling  on  closing  the  eyes,  etc.,  and  after  a  time  extend 
to  the  superior  extremities.     Early  the  handwriting  assumes  an  irregu- 


.588  DISEASES   OF   THE   NERVOUS   SYSTEM. 

lar,  trembling,  jerking  character,  and  at  length  becomes  impossible. 
The  resemblance  to  locomotor  ataxia  is  all  the  stronger,  since  there 
may  be  ocular  troubles,  double  vision,  amblyopia,  and  even  amaurosis, 
altered  sensations,  anaesthetic  tracts,  etc.,  about  the  body,  and  reten- 
tion or  incontinence  of  urine  and  faces.  These  locomotor  ataxia  symp- 
toms, we  may  assume  with  propriety,  result  from  the  sclerotic  nodules 
deposited  in  the  posterior  columns,  but  a  granular  myelitis  attacks  the 
lateral  columns  in  a  smaller  proportion  of  cases,  when  there  will  occur 
the  peculiar  shuffling  and  helpless  gait  and  the  anaesthesia  belonging 
to  this  lesion.  A  paretic,  ultimately  paralytic  state  of  the  facial  nerve 
occurs  in  many  cases,  and  the  muscular  system  generally  is  thus  af- 
fected. Hemiplegia,  usually  transient  as  regards  the  motor  functions, 
is  often  the  result  of  an  apoplectic  seizure  which  may  inaugurate  the 
symptoms,  or  occur  at  any  period  during  the  course  of  the  disease. 
Instead  of  motor  hemiplegia,  sensory  hemiplegia  may  result  from  a 
sudden  attack  with  loss  of  consciousness.  Although  such  motor  and 
sensory  symptoms  disappear  very  quickly,  the  mental  condition  is 
always  much  injured  by  these  attacks.  During  the  course  of  the  dis- 
ease, epileptiform  seizures  also  occur  ;  they  may  be  unilateral  or  gen- 
eral, severe  or  mild.  Epilepsia  mitior,  petit  mal,  with  loss  of  conscious- 
ness, but  no  convulsive  phenomena,  may  be  substituted  for  the  severe 
attacks  or  occur  with  them.  Death  may  happen  in  the  coma  which 
follows  an  attack,  or  a  decided  remission  in  the  symptoms,  with  appar- 
ent improvement  in  the  mental  state,  may  follow. 

Course,  Duration,  and  Termination. — Dementia  paralytica  is  a  chron- 
ic disease,  but  its  duration  can  not  be  fixed  very  accurately,  owing  to 
the  uncertainty  which  attends  the  time  of  the  initial  symptoms.  It  may 
be  said  that  the  cases  vary  in  duration  from  one  to  ten  years.  It  is 
true  deaths  have  been  reported  as  occurring  within  a  year,  or  in  a  few 
months,  but  there  must  be  doubts  in  regard  to  the  diagnosis  in  such 
cases.  When  the  disease  begins  by  apoplectic  phenomena,  the  prog- 
ress may  be  more  rapid  ;  and,  when  such  attacks  occur  during  the 
height  of  the  malady,  the  progress  downward  is  accelerated,  although 
the  injury  caused  by  the  apoplexy  is  largely  recovered  from.  The 
usual  course  is  a  gradual  increase  in  the  paresis  ;  the  countenance  be- 
comes more  blank,  expressionless,  and  the  muscles  more  relaxed  ;  irreg- 
ular jactitations  occur  in  the  facial  muscles  whenever  speech  is  at- 
tempted or  emotions  are  felt ;  the  mode  of  speech  becomes  more  and 
more  stammering,  and,  as  the  memory  becomes  more  and  more  de- 
ficient, words  are  omitted  so  extensively  that  the  speech  is  unintelli- 
gible. The  voluntary  efforts  are  so  enfeebled  that  no  movements  can 
be  undertaken,  and  hence  the  patient  sits  motionless,  or  is  finally  bed- 
ridden, passing  his  urine  and  faeces  involuntarily.  Toward  the  end  the 
nutrition  fails,  the  body  wastes,  and  an  extreme  emaciation  is  the 
result ;  rarely  the  face  is  full  and  flabby,  the  abdomen  prominent. 


DEMENTIA  PARALYTICA.  589 

The  tongue  becomes  more  and  more  paretic,  swallowing  increasingly- 
difficult,  and  particles  of  food  drop  into  the  larynx,  exciting  suffocative 
attacks.  Death  may  be  caused  by  a  pneumonia  thus  excited,  or  may 
occur  by  an  apoplectic  seizure,  or  in  the  coma  succeeding  a  fit,  or  may 
be  due  to  the  exhaustion  resulting  from  bed-sores.  A  considerable 
proportion  are  carried  off  by  phthisis.  It  occasionally  happens  that  a 
remarkable  remission  takes  place  in  the  condition  of  the  general  para- 
lytic when  it  seems  hopeless.  The  speech  improves,  the  paresis  of  the 
muscular  system  disappears,  and  normal  strength  is  restored,  reason 
and  judgment  return  again,  and  hallucinations  and  illusions  no  longer 
occur.  This  I'emission  may  last  a  short  time,  the  disease  revive,  and 
the  progress  into  its  worst  phases  be  again  very  rapid.  On  the 
other  hand,  the  remission  may  pass  on  to  complete  restoration,  the 
patient  being  restored  to  his  friends  and  his  work  in  life.  This  for- 
tunate result  is  extremely  uncommon,  but  has  occurred  often  enough 
to  require  the  utmost  circumspection  in  giving  an  opinion.  Except 
these  cases,  there  is  little  to  encourage  in  the  course  and  results  of  this 
melancholy  disease. 

Diagnosis. — The  differentiation  of  dementia  paralytica  is  easily  de- 
cided when  the  symptomatology  is  complete.  The  expansive  ideas, 
the  paralysis,  the  failure  of  memory,  the  lack  of  all  moral  feelings,  suf- 
ficiently indicate  the  nature  of  the  malady  ;  but  the  cases  not  fully  de- 
veloped may  be  recognized  with  difficulty.  The  defects  of  speech,  of. 
intelligence,  and  the  existence  of  paralyses  with  ataxic  symptoms, 
serve  to  distinguish  dementia  paralytica  from  posterior  spinal  sclero- 
sis. From  senile  dementia  the  differentiation  is  made  by  reference  to 
the  expansive  ideas,  the  moral  state,  the  peculiar  affection  of  speech, 
the  existence  of  ataxia  and  paralyses,  and  the  age  at  which  the  phe- 
nomena became  manifest. 

Treatment. — The  therapeutics  of  this  disease  are  in  an  unsatisfac- 
tory state.  As  these  cases  occur  in  private  practice,  they  are  difficult  to 
handle  because  of  their  peculiar  mental  condition.  Above  all  other 
cases,  if  we  except  acute  mania,  and  the  suicidal,  there  are  none  need- 
ing more  the  restraint  of  asylum  treatment.  In  the  attempt  to  put 
them  into  the  asylum  early,  serious  difficulties  are  encountered  ;  for 
they  are  very  plausible,  and  easily  obtain  legal  assistance.  Above  all 
things,  these  subjects  require  rest,  both  of  body  and  mind,  and  care- 
fiil  alimentation.  The  most  suitable  remedies  are  lactophospate  of 
lime  and  cod-liver  oil,  with  quinia  and  morphia,  to  improve  the  nutri- 
tion of  the  brain  and  to  obtain  re|30se  at  night.  Good  results,  of  a 
temporary  character,  have  been  obtained  from  physostigma.  To 
quiet  restlessness  and  procure  sleep,  hyoseyamia  (-jV  to  -^  grain) 
has  been  used  with  excellent  effect  hypodermatically.  Chloral  and 
morphia  are  often  indispensable  for  this  jjurpose,  and  in  consider- 
able doses.     To  procure  rest  and  sleep,  and  a  nutritious   and   care- 


590  DISEASES   OF   THE   NERVOUS   SYSTEM. 

ful  alimentation,  offer  the  best  prospects  of  affording  relief   in  this 
disease. 

SYPHILIS  OF  THE   NERVOUS   SYSTEM. 

Definition. — By  syphilis  of  the  nervous  system  is  meant  deposits  of 
the  secondary  and  tertiary  stages,  so  called,  in  the  meninges,  in  the 
substance  of  the  brain  and  cord,  and  in  the  peripheral  nerves. 

Causes. — The  nervous  system  is  affected  coincidently  with  the 
other  viscera.  The  disease,  pursuing  its  regular  course,  attacks  the 
skin  and  mucous  membrane,  then  the  deeper  organs  and  tissues.  There 
is  no  fixed  period  for  the  appearance  of  syphilitic  deposits  in  the  ner- 
vous system.  Susceptibility  increases  the  rate  of  diffusion  of  the  poi- 
son, and  there  may  be  variations  in  its  intensity,  so  that  there  may  be 
considerable  variations  in  the  time  when  the  viscera  are  reached.  It 
may  be  stated,  in  general,  that  the  infection  of  the  nervous  system 
takes  place  during  the  latter  secondary  or  tertiary  period — in  from 
one  to  three  years  usually  ;  but  it  may  occur  within  one  year,  or  be 
postponed  twenty  years.  In  a  large  number  of  cases — the  author  has 
seen  several — the  nervous  is  the  only  secondary  affection  ;  but  usu- 
ally other  lesions  have  existed,  and  in  one  third  relapses  have  oc- 
curred. The  disposition  of  syphilis  to  attack  a  particular  part  may  be 
determined  by  existing  injury  or  disease,  or  hereditary  or  acquired 
.tendency  to  disease  ;  and  this  is  true  of  syphilis  of  the  nervous  sys- 
tem. All  the  causes,  therefore,  that  tend  to  bring  about  disorders  in 
the  nervous  system  will  determine  attacks  of  syphiloma. 

CEREBRAL   SYPHILIS. 

Pathological  Anatomy. — The  syphilitic  masses,  known  as  gummata, 
form  in  the  subarachnoid  space,  or  on  the  inner  surface  of  the  dura, 
and  grow  toward  the  brain.  There  is  also  a  syphilitic  pachymenin- 
gitis, which  occurs  at  the  convex  surface  of  the  hemispheres,  especially 
at  the  base  forward  on  the  anterior  lobes,  and  at  the  base  about  the 
sella  turcica.  It  is  the  external  form,  and  is  usually  associated  with 
bony  lesions,  and  with  the  two  forms  of  gummata.  These,  springing 
from  the  inner  surface  of  the  dura  and  from  the  subarachnoid  space, 
are  the  most  important  of  the  syphilitic  new  formations.  The  first 
variety  of  gummata  consists  of  a  soft,  reddish,  translucent  mass,  com- 
posed of  round  cells  and  nuclei,  spindle  and  stellate  cells,  distributed 
through  the  tissue  of  the  part ;  and  hence  the  density  of  the  result- 
ing mass  is  determined  by  the  character  of  the  tissue  in  which  these 
cells  are  deposited,  A  number  of  cells  may  be  closely  packed  in  a 
considerable  interspace,  forming  an  alveolar  arrangement,  or,  exuded 
into  a  reticulated  tissue,  will  have  a  corresponding  appearance.  The 
new  tissue  contains  capillary  blood-vessels,  and  there  may  be  extrava- 


CEREBRAL  SYPHILIS.  591 

sations  by  their  rupture.  This  form  is  not  separated  hj  a  sharp  boun- 
dary from  the  normal  tissue,  but  the  cells  push  out  into  their  surround- 
ings. The  other  form  of  gumma  is  not  so  soft  and  translucent,  but 
is  dry,  firm,  and  yellowish,  so  that  it  is  sometimes  said  to  be  fatty, 
but  is  really  a  cheesy  transformation.  They  exist  in  two  forms  :  as  a 
diffuse  infiltration,  and  in  circumscribed,  well-defined  masses,  varying 
in  size  from  a  pea  to  a  pigeon's-egg.  A  favorite  site  of  this  gumma  is 
inclosed  between  the  two  layers  of  the  dura,  where  it  may  attain 
considerable  size.  When  the  gummata  form  at  the  convexity,  it  is 
found  that  the  granulation-tissue  has  completely  united  and  blended 
the  membranes,  so  that  they  are  not  distinguishable.  Here  the  yellow 
masses  may  lie  imbedded  in  the  grayish-red  gumma,  and  about  the 
mass,  the  brain-substance  into  which  the  neoplasm  projects,  is  in  a 
state  of  white  or  red  softening.  At  the  base  the  gummata,  developing, 
fill  in  all  the  interstices  around  the  chiasm,  the  crura,  and  the  pons. 
Here  the  grayish-red  growth  is  chiefly  seen.  By  developing  into  the 
adjacent  brain-substance,  it  causes  softening.  A  syphilitic  new  for- 
mation also  occurs  in  the  vessels  of  the  base.  The  affected  vessel  is 
thickened,  grayish,  and  hard,  by  the  deposits  which  form  a  cylinder  ; 
the  lumen  of  the  vessel  is  encroached  on,  so  that  it  transmits  only 
one  half  or  one  fourth  the  usual  quantity  of  blood.  When  this  change 
occurs  in  several  of.  the  vessels,  the  cerebral  circulation  is  much  em- 
barrassed. It  will  suffice  to  say  that  the  changes  consist  in  the  forma- 
tion of  granulation-tissue  in  the  tunics  of  the  vessel,  the  morbid  pro- 
cess beginning  in  the  intima.  Besides  the  gummata,  the  meninges  may 
be  affected  by  a  syphilitic  inflammation,  which  consists  in  the  forma- 
tion of  thick  and  rather  tough  patches,  which  do  not  differ  in  struc- 
ture from  the  gummata.  Inflammation  may  also  take  place  in  the 
brain-substance,  and  terminate  in  softening. 

Symptoms. — The  first  symptom  is  headache  ;  it  is  usually  very  se- 
vere, and  has  this  peculiarity,  that  it  is  much  worse  at  night,  and  may 
indeed  be  felt  only  at  night.  The  pain  may  disappear  spontaneously, 
to  return  again,  sometimes  after  a  brief  and  sometimes  after  a  long 
interval,  but  is  usually  continuous  ;  *  it  is  increased  by  a  slight  tap  on 
the  head,  and  its  position  may  indicate  the  seat  of  the  lesion  (Lance- 
reaux).  The  severe  nocturnal  pain  causes  wakefulness,  but  this  symp- 
tom may  be  present  when  there  is  no  pain.  Vertigo,  confusion  of 
mind,  irritability,  inability  to  apply  the  mind  to  any  subject,  and  mel- 
ancholy, with  suicidal  feelings,  are  symptoms  experienced  with  more  or 
less  severity  from  the  time  when  the  new  formations  begin  to  develop, 
and  may  be  due  to  congestion  as  supposed  by  Lancereaux,  but  also  to 
compression  of  the  intra-cranial  contents.  After  a  time,  fainting-at- 
tacks  occur  without  any  special  cause  ;  weakness  is  experienced  in  the 

*  Lancereaux,  "  Treatise  oh  Syphilis,"  Sydenham  Society  edition,  vol.  xi,  p.  46. 


592 


DISEASES   OF   THE   NERVOUS   SYSTEM. 


legs,  wtich  give  way  unexpectedly  ;  there  may  be  defects  of  speech 
from  inability  to  articulate  ;  loss  of  the  memory  for  words,  exceeding 
slowness  of  speech ;  dimness  of  vision  (amblyopia),  with  double 
vision  unequal  pupils,  strabismus,  the  ophthalmoscopic  examination 
showing  swollen  disks,  distended  and  tortuous  vessels,  etc.;  noises  in 
the  ears  and  dullness  of  hearing;  there  may  be  maniacal  symptoms,  but 
more  frequently  the  kind  of  mental  defects  mentioned  above;  epilepti- 
form attacks  succeed  to  the  fainting,  and  they  may  be  partial,  limited 
to  one  extremity,  without  loss  of  consciousness,  or  general,  with  uncon- 
sciousness. There  may  be,  and  usually  are  in  basal  deposits,  defects 
of  coordination,  unstable  gait,  excessive  vertigo,  nausea,  and  vomiting, 
rapid  impairment  of  vision,  swollen  eyelids,  bleeding  at  the  nose,  etc. 
There  are  other  motor  defects,  besides  the  impaired  coordination  and 
reeling  gait :  paresis  of  the  muscles  of  one  side,  including  the  face, 
coming  on  slowly  without  an  apoplectic  seizure  ;  there  may  be  a  mere 
weakness  of  one  extremity,  dragging  of  the  foot  a  little,  inefficient  use 
of  an  arm,  but  still  preservation  of  its  motions,  or  it  may  be  limited 
to  one  side  of  the  face.  In  many  cases  there  are,  besides  the  motor  dis- 
orders, bilateral  affections  of  sensibility  ;  there  may  be  neui-algia  (tic- 
douloureux  or  sciatica),  but  more  frequently  the  sensations  are  depressed 
— there  are  extensive  tracts  on  both  sides,  of  complete  loss  of  the  sense 
of  pain  (analgesia)  and  of  the  sense  of  touch  (anaesthesia),  which,  again, 
in  other  cases,  may  be  more  or  less  perfectly  preserved.  There  is  an- 
other group  of  cases  in  which,  preceded  by  the  symptoms  which  an- 
nounce the  growth  of  the  new  formations,  but  which  may,  however, 
be  not  very  decided  in  their  manifestation,  there  occur  sudden  apo- 
plectic seizures,  varying  in  severity  from  profound  unconsciousness 
to  a  momentary  dazed  feeling,  after  which  a  hemiplegia  is  found  to 
exist  (Huebner).*  These  attacks  with  the  resulting  lesions  may  proceed 
in  the  usual  way,  of  course  very  much  influenced  by  the  treatment, 
but  in  a  certain  proportion  of  the  cases  they  lie  in  a  somnolent  or  partly 
somnolent  condition,  from  which  they  may  be  awakened,  but  at  once 
lapse  back.  These  attacks  are  usually  preceded  by  headache,  by  a  feel- 
ing of  exhaustion,  and  by  a  stupid,  inactive  mental  state,  which  may 
pass  slowly  into  the  condition  of  somnolence.  During  this  state,  acts 
are  performed  like  those  of  a  somnambulist,  as  in  getting  up  to  uri- 
nate, etc.;  and  when  roused  they  awaken,  gaping  and  yawning,  but 
coherent,  yet  soon  lapse  back  into  stupor,  with  an  air  of  protest  at 
having  been  disturbed.  These  periods  of  somnolence  vary  in  dura- 
tion ;  usually  continue  from  night  to  the  following  afternoon,  and, 
as  in  a  case  lately  seen  by  the  author,  the  usual  times  of  sleep  are 
disturbed  by  severe  nocturnal  headache.  Often,  but  not  always, 
these   somnolent  periods    are  accompanied  by   fever   of   a   remittent 

Ziemssen's  "  Cyclopaedia,"  vol.  xii. 


SPINAL  SYPHILIS.  593 

type.  The  somnolent  period  may  last  a  few  days,  even  several  weeks, 
and  may  proceed  to  deeper  coma  ending  in  death,  or  the  stupor  may 
grow  less  dense,  the  intervals  of  wakefulness  longer,  and  ultimately 
the  somnolence  disappears  entirely.  Cerebral  syphiloma  manifests 
itself  by  still  another  group  of  symptoms,  namely,  those  of  dementia 
paralytica.  It  begins  with  various  symptoms  of  irritation  in  the  in- 
tellectual sphere — confusion  of  mind,  irritability,  melancholy  of  an 
expansive  kind,  and  ideas  of  grandeur.  These  symptoms  may  appear 
and  disappear,  and  long  intervals  elapse,  until  at  length  symptoms  of 
weakness  come  on,  with  such  abnormal  sensations  as  numbness,  tin- 
gling, and  formication,  followed  by  inability  for  any  considerable  exer- 
tion, incoordination  of  movements,  paralyses.  The  mental  condition 
ultimately  is  that  of  dementia. 

Course,  Duration,  and  Termination. — There  are  no  maladies  in 
which  the  results  of  treatment  are  more  conspicuous  for  good,  and 
which  are  more  influenced  in  their  course,  duration,  and  termination. 
The  second  form  of  Huebner,  characterized  by  the  apoplectic  phenom- 
ena, followed  by  hemiplegias,  is  the  shortest  in  duration,  the  lesions 
being  chiefly  in  the  vessels.  Even  if  a  cure  does  not  take  place,  im- 
provement may  be  effected,  and  the  duration  not  be  less  than  four 
years.  In  the  second  form,  the  opportunities  for  successful  treatment 
are  numerous,  and  the  results  under  an  appropriate  medication  very 
striking.  Without  treatment,  weeks  and  months  may  pass  before  the 
final  result  is  reached.  The  form,  so  like  dementia  paralytica,  is  more 
protracted,  is  subject  to  great  fluctuations,  and  may  continue  for  sev- 
eral years.  Notwithstanding  the  curability  of  many  cases — those,  for 
example,  with  hemiplegia,  or  local  paralyses,  and  with  repeated  epi- 
leptiform seizures — yet  many  cases  resist  the  best-directed  efforts,  and 
for  reasons  that  are  obvious  :  the  gummata,  by  pressure,  produce  soft- 
ening and  destruction  of  nerve-tissue,  which  can  not  be  replaced. 
Furthermore,  syphilitic  cerebral  affections  manifest  a  great  tendency 
to  relapse  after  apparent  cure. 

SPINAL    SYPHILIS. 

Pathological  Anatomy.— As  in  the  brain,  gummata  spring  from  the 
internal  surface  of  the  dura,  grow  into  the  nervous  matter,  and  unite 
the  membranes  in  a  compact  mass.  They  have  the  structural  pecu- 
liarities of  gummata  in  the  brain  and  elsewhere  (Moxon  *).  Softening 
of  the  cord  is  a  result  of  the  presence  of  these  new  formations  ;  partly 
due  to  pressure  and  partly  to  development  inwardly  of  the  neoplasm. 
Syphilitic  disease  occurs  in  the  bones  of  the  vertebrge,  in  the  connective 
tissue,  and  in  the  outer  layer  of  the  dura,  producing  the  symptoms  of 
compression. 

*  "  On  Syphilitic  Disease  of  the  Spine,"  "  Guy's  Hospital  Ecports,"  vol.  xvi,  1870. 
38 


594  DISEASES   OF   THE   NERVOUS   SYSTEM. 

Symptoms. — Long  after,  often  many  years,  after  the  specific  local 
lesion,  deposits  occur  in  the  spinal  canal.  According  to  the  author's  ob- 
servation *  the  spinal  troubles  may  be  coincident  with  the  development 
of  fresh  tertiary  symptoms  elsewhere.  The  most  constant  symptom  is 
a  deep-seated  pain  in  the  dorsal  or  lumbar  region,  increasing  at  night ; 
a  pain  of  such  severity  as  to  require  powerful  anodynes  to  obtain  suf- 
ficient relief  for  sleep.  There  may  or  may  not  be  tenderness  on  pres- 
sure. Usually  a  great  deal  of  pain  is  experienced  in  one  or  both  of 
the  sciatic  nerves,  and  tingling,  numbness,  and  burning  sensations  in 
the  legs  and  feet.  More  or  less  weakness,  a  strong  sense  of  fatigue  on 
slight  exertion,  stiffness  and  cramps  are  experienced  in  the  muscles  of  the 
spine,  of  the  neck,  and  of  the  extremities.  As  the  disease  is  develop- 
ing, the  general  system  sympathizes  to  a  remarkable  extent ;  a  peculiar 
earthy  hue  of  the  face,  emaciation,  and  debility  are  observed.  The 
symptoms  may  continue  at  this  point  for  a  long  time,  or  partial  im- 
provement take  place,  and  then,  after  some  weeks  or  months  of  inac- 
tion, more  serious  symptoms  come  on.  When  the  symptoms  become 
active  again,  paralysis  begins  and  proceeds  with  great  rapidity,  and 
becomes  so  complete  that  not  a  toe  is  movable.  The  paralysis  may  be 
due  to  disease  of  the  dorso-lumbar  enlargement,  and  both  lower  limbs 
be  completely  paralyzed  (paraplegia)  as  to  motion,  sensation,  and  the 
reflexes.  The  sphincters  will  also  be  involved,  and  incontinence  be 
added  to  the  other  troubles.  There  may  be  partial  paralysis,  one  limb 
involved.  When  the  arms  are  affected,  there  will  be  oculo-pupillary 
phenomena,  and  the  respiratory  muscles  will  be  paretic  or  paralyzed  if 
the  disease  is  high  up  in  the  cervical  region.  These  spinal  troubles  of 
syphilitic  origin  may  be  associated  with  corresponding  cerebral  lesions, 
when,  of  course,  the  symptoms  will  partake  of  both.  There  is  a  form 
of  acute  spinal  paralysis  described  by  Huebner  which  comes  on  during 
the  first  secondary  symptoms,  and  is  characterized  by  a  sudden  para- 
plegia or  paralysis  of  one  arm  and  the  opposite  leg.  In  a  few  hours, 
or  a  day  or  two,  the  mischief  is  wrought,  and  the  paralysis  complete. 

Course,  Duration,  and  Termination. — The  course  of  the  principal 
forms  of  spinal  lesions  is  very  protracted,  and  they  appear  long  after 
the  local  primary.  Rightly  treated  they  get  well  promptly,  but,  as  is 
the  case  with  the  cerebral  disease,  they  are  prone  to  relapse,  yet  the 
ultimate  cure  is  probable.  When  paraplegia  has  occurred  with  abso- 
lute paralysis,  a  cure  may  often  be  effected  in  a  few  weeks  ;  but  that 
this  favorable  termination  shall  take  place  it  is  essential  that  the  in- 
jury be  recent.  If  the  cord  has  been  damaged,  permanent  disability 
will  remain,  although  the  disease  may  be  arrested.  Old  cases  may 
terminate  fatally  by  exhaustion  from  cystitis  and  bed-sores.  The 
acute  form,  described  by  Huebner,  seems  to  be  very  unmanageable, 

*  "  On  Syphilis  of  the  Nervous  System,"  "  The  Clinic,"  1874. 


EPILEPSY.  595 

and  to  reach  a  fatal  termination  by  extension  upward.     In  the  spinal 
as  in  the  cerebral  form,  much  depends  on  the  treatment  instituted. 


SYPHILIS    OF    THE    NERVES. 

Pathological  Anatomy. — The  cerebral  nerves  seem  to  be  chiefly  if 
not  the  only  nerves  attacked  by  syphilis.  The  deposits  may  be  exte- 
rior, and  press  on  the  nerve-trunks,  producing  a  neuritis,  which  leads 
to  atrophic  changes  and  degeneration.  A  gumma  surrounding  a  nerve- 
trunk  unprovided  with  a  sheath  will  grow  into  the  tissues  of  the  nerve^ 
and  syphilitic  granulation-tissue  may  deposited  in  places,  and  develop 
in  the  ordinary  way. 

Symptoms. — The  results  of  such  affections  of  nerve-trunks  have  a 
different  expression  according  to  the  function  of  the  nerve.  Irritation 
of  a  sensory  nerve  produces  pain  in  its  peripheral  distribution  ;  but,  if 
the  nerve  is  destroyed,  anaasthesia  and  analgesia  are  experienced.  On 
the  other  hand,  if  a  motor  nerve  is  irritated,  spasms  or  tonic  con- 
traction will  ensue  in  the  muscles  to  which  this  nerve  is  distributed  ; 
if  the  nerve  is  destroyed,  paralysis  ensues.  As  the  cerebral  nerves 
are  usually  affected,  the  same  symptoms  result  from  syphilitic  neo- 
plasms as  have  been  described  in  connection  with  other  neoplasms 
or  tumors  of  the  brain. 

Diagnosis  of  Syphiloma  of  the  Nervous  System.— The  first  point  to 
determine  is  the  occurrence  of  syphilitic  infection.  The  peculiarities 
of  the  syphilitic  affections  of  the  brain  are  their  diffusion,  the  irregu- 
larity in  the  development  of  the  symptoms,  the  simultaneous  exist- 
ence of  irritation  and  depression,  the  periods  of  spontaneous  improve- 
ment, the  remarkable  change  in  the  condition  of  a  patient  receiving 
iodide  of  potassium  or  mercury  in  some  form,  etc. 

Treatment. — In  these  affections  the  most  marvelous  change  is 
wrought  by  sufiicient  doses  of  the  iodide  of  potassium.  No  time  is 
to  be  lost  in  its  administration,  and  usually  the  largest  doses  are  re- 
quired. Sometimes  mercury  does  better,  and  lesions  do  not  yield  until 
it  is  administered. 


CEREBRO-SPIJ^AL  NEUROSES. 


EPILEPSY. 

Definition. — By  the  term  epilepsy,  as  here  employed,  is  meant  true 
or  essential  epilepsy,  and  not  eclampsia,  nor  convulsion  from  such  cause 
as  tumor,  abscess,  etc.,  of  the  brain. 


596  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Causes. — Heredity  occupies  the  first  place  as  an  etiological  factor. 
In  Echeverria's  *  cases,  about  twenty-five  per  cent.,  and  in  Reynolds's  f 
about  thirty  per  cent,  were  distinctly  due  to  hereditary  transmission. 
It  is  a  neuropathic  constitution  or  tendency  which  is  inherited,  and  this 
exhibits  itself  in  various  forms  in  different  generations.  In  one  gen- 
eration it  is  neuralgia,  nervousness,  paralysis  ;  in  another,  epilepsy  ;  in 
a  third,  insanity.  Next  to  the  inheritance  of  a  neurotic  tendency,  in 
point  of  importance  as  a  cause,  is  the  influence  of  drunkenness  in  the 
father  on  the  product  of  conception.  Sexual  excesses  and  onanism  are 
held  to  be  frequent  causes,  but  much  exaggeration  has  existed  in  re- 
gard to  their  effects  in  this  way.  They  are  more  frequently  the  result 
than  the  causes  of  epilepsy.  As  regards  age,  the  greatest  number  of 
cases  occur  in  the  decennary  from  seven  to  seventeen.  As  regards  sex, 
the  two  are  about  equal  in  their  liability  to  the  disease.  According  to 
Reynolds,  not  one  case  which  was  hereditary  began  after  twenty,  while 
twenty-six  per  cent,  of  those  not  hereditary  were  affected  after  twenty. 
Irritation  of  peripheric  nerves,  dentition,  and  injuries  to  the  cranium, 
are  among  the  occasional  causes.  Epileptic  seizures  have  been  ex- 
cited by  various  psychical  impressions — by  fear,  by  irritation,  by  cha- 
grin, and  other  powerful  emotions. 

Pathological  Anatomy. — There  is  no  morbid  alteration  peculiar  to 
epilepsy.  In  this  important  respect  true  epilepsy  differs  from  epilep- 
tiform seizures.  Although  there  is  no  special  change,  various  acci- 
dental pathological  alterations  are  found  in  the  cranial  cavity.  Changes 
in  the  contour  and  structure  of  the  skull ;  thickened,  indurated,  and 
calcareous  meninges  ;  increase  in  weight  of  the  brain  according  to 
some  (Echeverria),  and  diminution  of  weight  according  to  others  ; 
changes  in  the  hippocampus  (Meynert)  ;  tumors  of  the  cortex  ;  varia- 
tions in  the  distribution  of  the  gray  matter — are  gross  lesions  which 
have  been  ascertained  to  exist  in  old  cases  of  epilepsy.  Long  ago 
Schroeder  Van  der  Kolk  |  found  alterations  in  the  medulla,  consisting 
in  dilatation  of  the  arterioles  and  fatty  degeneration  of  their  tunics. 
Echeverria  §  confirmed  these  observations  and  added  investigations  of 
his  own,  to  the  effect  that  not  only  are  the  vessels  enlarged,  their 
tunics  fatty,  but  that  hyperplasia  of  the  neuroglia  and  atroj^hy  of  the 
cells  of  the  medulla  are  constant  changes  in  epilepsy.  The  same  author 
has  ascertained  the  existence  of  sclerotic  changes  in  the  ganglia  of  the 
sympathetic,  but  the  relation  which  such  changes  bear  to  the  produc- 
tion of  epilepsy  is  by  no  means  clear. 

Symptoms. — The  phenomena  of  epilepsy  are  exhibited  in  two  forms 

*  "  On  Epilepsy,"  by  M.  Gonzales  Echeverria,  M.  D.,  New  York,  1870. 
f  "Epilepsy,"  etc.,  by  J.  Russell  Reynolds,  1861,  p.  123. 

X  "  On  the  Minute  Structure  and  Functions  of  the  Spinal  Cord,"  Sydenham  Society 
edition,  1859,  p.  231,  et  seq. 
§  Op.  cit.,  chapter  xi,  p.  46. 


EPILEPSY.  597 

of  seizures,  and  in  tlie  state  of  the  affected  individual  in  the  inter- 
val between  the  convulsive  or  unconscious  attacks.  The  epileptic 
seizures  are  :  epilepsia  gravior,  the  severer  epilei3sy,  the  epileptic 
fit,  called  by  the  French  writers  le  grand  inal,  and  epilepsia  mitior, 
milder  epilepsy,  le  petit  tnal.  Adopting  the  classification  of  Jac- 
coud,  we  have  the  first  form  occurring  in  two  modes — the  common 
or  ordinary  form,  and  the  apoplectic  /  the  second  also  in  two — ver- 
tigo and  absence.  Many  cases  of  the  common  form  begin  without 
any  indication  of  their  approach,  but  a  certain  number  are  preceded 
by  definite  sensations  and  warnings.  The  term  aura  is  applied  to  a 
singular  phenomenon  preceding  the  attack  and  indicating  its  approach. 
No  longer  used,  in  accordance  with  its  original  signification,  as  a  breath, 
this  term  expresses  any  manifestation,  sensory,  motor,  or  psychical, 
which  gives  warning  of  a  paroxysm  :  it  may  be  the  sensation  of  a 
breath,  the  flowing  of  a  hot  or  cold  liquid,  numbness,  tingling,  even  a 
severe  pain  passing  with  great  rapidity  from  the  periphery  to  the 
brain.  Again,  the  aura  may  consist  of  an  impression  on  an  organ  of 
sense,  as  a  flash  of  light,  a  strange  odor,  or  a  rumbling  noise  in  the 
ear  ;  or  in  some  local  muscular  spasm  or  cramp  ;  or  some  specter  or 
other  hallucination  rising  up  in  the  mind.  Warnings  may  be  more 
remote,  occurring  some  days  before  the  seizure,  when  they  take  the 
shape  of  mental  or  moral  perturbation  ;  sadness  and  despondency  of 
mind,  a  gloomy  reticence  and  suspicion  are  experienced,  or  an  excited, 
irritable,  quarrelsome,  even  dangerous  and  malignant  state  of  mind 
comes  on.  More  frequently  than  these  symptoms  occur  merely  head- 
ache, dizziness,  and  some  confusion  of  mind,  for  a  few  hours  or  a  day 
or  two  before  the  seizure.  In  a  large .  proportion  of  cases  seen  by  the 
author,  the  prodromal  symptoms  consisted  in  a  sense  of  praecordial 
oppression,  epigastric  uneasiness,  and  nausea,  the  attack  following 
immediately  on  the  rise  of  a  peculiar  sensation  from  the  epigastrium 
to  the  brain.*  With  or  without  an  aura,  the  epileptic  paroxysm  when 
it  occurs  is  sudden.  It  consists  of  four  distinct  acts  :  a  sudden  fall  ; 
loss  of  consciousness,  with  pallor  of  the  face  ;  a  peculiar  cry  ;  general 
convulsions.  In  any  situation  or  place  the  individual  attacked  hap- 
pens to  be,  he  falls — down  the  stairway,  into  the  fire,  against  an  article 
of  furniture  ;  or  if,  mercifully  warned  by  some  sensation,  he  has  the 
opportunity,  he  places  himself  in  a  position  of  safety.  The  fall  may 
be  to  one  particular  side,  on  which  scars  will  be  found  to  indicate  the 
direction  taken  in  falling.  The  fall  occurs  because  loss  of  conscious- 
ness supervenes,  and  the  control  is  at  once  withdrawn  from  the  volun- 
tary muscular  system.  Sensibility,  motility,  perceptions,  the  special 
senses,  the  reflex  functions  even,  are  at  once  and  entirely  abolished. 
The  face  grows  deadly  pale,  and  this  is  due  to  a  sudden  spasm  of  the 

*  Gowers  ("  Gulstonian  Lectures,"  "  Lancet,"  March  20,  1880)  says   this   sensation 
occurred  in  one  half  of  his  cases. 


598  DISEASES   OF   THE   NEKYOUS   SYSTEM. 

arterioles  of  the  head,  whence  the  amount  of  blood  passing  to  the 
brain  is  greatly  reduced.  At  the  moment  that  unconsciousness  takes 
place,  a  peculiar  cry  is  uttered,  "  shrill  and  terrifying  to  man  and 
beasts,"  is  the  description  of  Romberg.*  It  may  be  a  mere  groan,  and 
there  may  be  an  entire  absence  of  all  sound.  Immediately  on  the 
occurrence  of  pallor  of  the  face,  the  muscles  of  the  body  generally 
assume  a  position  of  tetanic  rigidity  ;  the  head  is  drawn  back  or  to 
one  side,  where  it  is  firmly  held  ;  the  jaws  are  tightly  closed,  the 
lips  retracted  into  the  sardonic  grin,  the  eye  fixed  in  a  stern  expres- 
sion, the  brow  corrugated  ;  the  fingers  and  toes  are  extended,  widely 
separated  ;  the  respiratory  muscles  similarly  tetanized,  respiration  is 
suspended  ;  the  pulse  is  small,  firm,  and  variable  in  frequency  ;  a 
rapid  venous  stasis,  cyanosis  of  the  face,  and  blueness  of  the  lips  suc- 
ceed to  the  momentary  deathly  pallor,  because  of  the  arrest  of  respira- 
tion and  compression  of  the  great  venous  trunks  by  the  rigid  cervical 
muscles.  Just  as  the  tetanic  stage  begins,  a  loud,  strong,  and  pro- 
tracted whistling  inspiration  is  made,  and  then  ensues  the  rigidity  of 
the  respiratory  muscles.  The  tetanic  condition  may  not  be  universal, 
may  be  limited  to  a  few  muscles,  as  those  of  the  head  and  eyes,  the 
clonic  spasms  beginning  at  once  ;  or  there  may  be  no  rigidity,  the 
muscular  twitching  beginning  at  once,  or,  on  the  other  hand,  there  may 
be  nothing  more  than  transient  rigidity  of  the  voluntary  muscles. 
This  rigid  stage  lasts  from  a  minute  to  a  minute  and  a  half,  and  is 
succeeded  by  the  stage  of  clonic  convulsions.  At  first  the  muscles  of 
the  face,  lips,  tongue,  pharynx,  and  larynx  begin  to  twitch,  the  face 
to  make  horrible  grimaces,  the  eyes  to  roll  in  their  sockets.  The  face 
is  still  blue,  the  lips  blue,  but,  as  respiration  goes  on,  the  blueness  is 
mixed  with  red,  the  superficial  veins  are  swollen,  the  lips  are  extruded 
with  each  expiration  and  are  covered  with  froth,  often  with  bloody 
froth,  the  breath  issues  with  a  whistling,  stridulous  noise,  the  inspira- 
tion being  labored,  loud,  sonorous,  the  teeth  grind  together,  and  often 
the  cheek  or  tongue  is  caught  and  chewed,  thus  furnishing  the  blood 
which  is  mixed  with  the  froth.  The  muscles  of  the  extremities  are 
violently  agitated,  thrown  about,  and  with  such  violence  that  severe 
injuries  are  sustained,  even  fractures  of  the  long  bones  or  dislocations. 
Vessels  give  way  and  ecchymoses  of  greater  or  less  extent  are  formed 
about  the  eyelids,  and  in  the  mucous  membrane  of  the  tongue  and  lips. 
By  these  marks  may  be  ascertained  the  existence  of  nocturnal  epilepsy, 
which  otherwise  remains  undiscovered.  The  clonic  stage  lasts  one, 
two,  or  three  minutes,  and  its  close  is  announced  by  the  subsidence  of 
the  convulsions  ;  they  occur  less  and  less,  and  at  length  there  is  only 
an  occasional  twitch  of  the  muscles  about  the  mouth,  and  presently  all 
is  still,  the  individual  passing  into  deep  sleep,  in  which  the  iris,  before 

*  "  On  Nervous  Diseases,"  "  Sydenham  Society's  translation,"  by  Sieveking. 


EPILEPSY.  599 

dilated,  contracts,  the  respirations  become  regular,  deep,  and  full,  the 
muscular  system  relaxed,  and  the  skin  warm  and  perspiring.  There 
may  be,  indeed,  a  conditien  of  coma  lasting  several  hours  after  the 
convulsive  stage,  and  fecal  and  seminal  discharges  may  occur  involun- 
tarily. The  duration  of  the  comatose  stage  varies  from  a  few  minutes 
to  several  hours,  and  the  patient  rouses  with  a  rather  surprised,  or 
dazed,  or  sheepish  expression,  and  is  entirely  ignorant  of  the  affair 
through  which  he  has  just  passed,  unless  the  bitten  tongue  or  cheek 
reminds  him  of  former  experiences.  Usually  the  effect  on  the  mental 
and  moral  state  is  that  of  improvement,  and  the  patient  feels  better 
than  before.  Attacks  may  succeed  to  attacks.  "Without  coming  out  of 
the  condition  of  coma,  another  convulsion  succeeds  to  the  previous  one. 
In  other  cases  the  recovery  from  each  paroxysm  is  complete,  and  the 
convulsions  occur  with  a  distinct  interval  of  an  entirely  normal  state. 
The  number  of  paroxysms  during  a  period  of  twenty-four  hours  may 
be  from  one  to  fifty — even  more.  Immediately  succeeding  the  con- 
vulsions in  some  epilej)tics,  there  occur  attacks  of  delirium  or  hallu- 
cinations, or  they  pass  into  an  excitable,  quarrelsome  state,  and  are 
prone  to  commit  homicidal  acts.  Physicians  have  frequently  to  testify 
as  to  the  mental  condition  of  epileptics,  on  trial  for  acts  committed  in 
the  mania  which  succeeds  to  convulsions. 

The  apoplectic  form  of  Jaccoud  differs  from  the  ordinary  form 
just  described,  by  the  depth  and  duration  of  the  succeeding  stage  of 
coma,  by  the  evidences  of  cerebral  congestion  present,  and  by  the 
paralysis — temporary  or  more  permanent — usually  in  the  form  of 
hemiplegia,  succeeding  to  the  clonic  convulsions.  The  second  form — 
epilepsia  mitior,  milder  epilepsy,  or  petit  mat — exhibits  iself  in  the 
two  forms  of  vertigo,  or  vertiginous  sensations,  and  absence  or  in- 
stantaneous unconsciousness  in  the  sphere  of  ideation.  In  the  former, 
the  patient  is  seized  with  a  severe  vertigo,  in  which  all  surround- 
ing objects  are  in  motion,  and  he  is  unable  to  maintain  the  upright 
position,  and  would  fall  if  not  supported.  With  the  vertigo  there 
is  loss  of  consciousness  lasting  for  a  second,  when  the  normal  state 
is  restored.  Usually,  the  vertiginous  sensations  and  the  loss  of  con- 
sciousness are  accompanied  by  some  partial  convulsive  phenomena  ; 
as  grimaces,  twitching  of  the  muscles  of  the  face,  grinding  of  the 
teeth,  movements  of  rotation  of  a  member — of  the  arm,  for  examj^le 
— or  of  the  whole  body,  running  forward  suddenly.  On  an  instant 
consciousness  returns,  the  patient  looks  around  with  a  foolish  expres- 
sion, it  may  be,  and  the  attack  is  over.  By  absence  is  meant  ab- 
sence of  mind,  but  not  in  the  popular  sense — in  the  technical  sense, 
in  this  connection,  of  total  abolition  of  ideation,  for  an  instant  of 
time.  The  attack  may  occur  at  any  time,  and  consists  in  the  most 
transient  suspension  of  consciousness — in  the  midst  of  a  sentence,  sew- 
ing, walking,  or  writing  :  for  the  instant  all  thought  is  suspended  ; 


goo  DISEASES   OF   THE   NERVOUS   SYSTEM. 

the  sentence  being  uttered,  the  sewing,  the  walking,  or  the  writing  is 
stopped,  and  then  immediately  resumed,  so  that  the  brief  gap  may 
attract  no  attention.  Observing  the  appearance  of  the  individual  thus 
attacked,  there  will  be  seen  a  sudden  pallor  of  the  face  and  dilatation 
of  the  pupil,  but  no  other  objective  phenomena.  These  forms  of  epilep- 
sia mitior  may  precede,  for  a  long  time,  the  fully  developed  attacks, 
or  may  occur  with  them.  The  popular  notion  of  the  little  importance 
of  these  seizures  is  not  justified  by  the  results,  for  absence  is  particu- 
larlv  injurious  to  the  mental  faculties.  In  all  of  these  forms  of  epilepsy 
the  loss  of  consciousness  is  the  central  fact,  and  without  it,  according 
to  many,  there  can  be  no  epilej)sy.  There  are,  however,  numerous  ex- 
amples of  convulsions,  partial  and  general,  without  loss  of  conscious- 
ness. Dr.  Hughlings  Jackson  *  defines  epilepsy  as  "  a  sudden,  exces- 
sive, and  rapid  discharge  of  gray  matter  of  some  part  of  the  brain  on 
the  muscles."  It  does  not  necessarily  involve  the  loss  of  consciousness. 
His  notion  is  that  any  mass  of  gray  matter  may  get  into  a  highly  ex- 
cited state  by  some  kinds  of  irritation — "  reaches  very  high  tension 
and  very  unstable  equilibrium,  and  therefore  occasionally  'explodes.'  " 
Irritation  of  a  part,  the  destruction  of  which  causes  hemiplegia,  will 
induce  unilateral  convulsions  of  the  same  region.  Local  convulsions, 
as  in  an  arm,  for  example,  may  therefore  be  a  "  discharging  lesion  of 
a  small  extent  of  irritated  gray  matter."  There  are  masked  or  con- 
cealed epilepsies,  taking  the  form  of  tic-douloureux.  or  neuralgia  of 
the  fifth  nerve,  convulsive  tic,  or  histrionic  spasm,  and  angina  pectoris. 
After  a  time  the  paroxysms  assuming  these  forms  take  on  the  proper 
epileptic  character,  or  the  epileptic  seizure  alternates  with  its  counter- 
feit. Again,  epilepsy  may  take  the  form  of  an  acute  delirium  (Fal- 
ret's  delirium  epilep)ticuii%) .  The  peculiarity  of  this  affection  is  its 
sudden  and  unaccountable  appearance,  and  its  equally  prompt  and  un- 
expected disappearance.  Often  the  delirium  takes  the  form  of  an 
"  insane  impulse,"  in  which  acts  of  violence  are  committed,  or  of  ob- 
scene and  violent  language,  or  of  some  senseless  conduct.  It  may  be- 
come excessively  violent  and  destructive,  leading  to  the  performance 
of  atrocious  murders.  This  condition  of  mind  is  transient  and  disap- 
pears in  a  few  hours  or  in  a  day  or  two,  and  the  jDatient  is  either  to- 
tally unconscious  or  has  the  remembrance  as  of  a  vague  dream. 

Course,  Duration,  and  Termination. — Epilepsy  is  one  of  the  most 
chronic  of  diseases,  and  its  duration  numbers  many  years.  At  the  out- 
set there  may  be  many  months'  interval  between  the  attacks,  but,  as 
the  case  progresses,  the  attacks  increase,  and  the  intervals  between 
them  become  shorter.  The  periods  of  return  are  very  irregular.  Now 
and  then  attacks  strictly  antiperiodic  are  encountered,  and  others  are 
connected  with  the  menstrual  functions.     As  attacks  are  often  deter- 

*  "  A  Study  of  Convulsions,"  and  "  On  the  Investigation  of  the  Epilepsies,"  and  vari- 
ous papers. 


EPILEPSY.  601 

mined  by  preventable  causes,  the  number  may  be  much  increased  by 
indiscretions.  Among  these  are  indulgence  in  alcoholic  fluids,  sexual 
excesses,  and  errors  in  diet.  Probably  the  last  named  is  the  most 
important  of  these  noxious  influences.  Nocturnal  attacks  may  escape 
recognition  for  a  long  time,  and  the  origin  of  the  disease  dates  from 
some  diurnal  attack,  or  from  a  seizure  in  which  the  bitten  tongue, 
ecchymoses,  and  general  muscular  soreness  served  to  indicate  the 
nature  of  the  disturbance.  An  unexpected  decline  in  mental  power, 
changes  in  the  disposition,  and  impaired  health  in  certain  directions 
without  any  apparent  reason,  may  be  explained  by  nocturnal  ejaileptic 
attacks.  The  existence  of  epilejjsy  is  not  incompatible  with  a  condition 
of  perfect  health.  In  the  interval  between  the  attacks,  still  more  in 
the  future  progress  of  the  cases,  various  alterations  in  the  motor,  sen- 
sory, and  intellectual  sphere  are  produced.  In  the  motor  group  may 
be  mentioned  clonic  convulsions  or  clonic  or  tonic  spasms  in  a  single 
extremity,  or  group  of  muscles  ;  in  the  sensory,  numbness  of  certain 
areas  in  the  extremities,  headache,  neuralgia,  etc.  The  most  important 
results  of  epileptic  seizures  are  changes  in  the  intellect,  weakness  of 
memory,  impaired  judgment,  etc.,  gradually  increasing  until  ultimately 
these  unfortunates  pass  into  the  condition  of  dementia.  Occasional 
epileptic  attacks  do  not  seem  to  have  much  influence  on  the  condition 
of  the  mind,  and  in  confirmation  of  this  opinion  are  always  quoted  the 
cases  of  Csesar,  Napoleon,  and  Petrarch.  The  statistics  of  Reynolds 
prove  that  the  number  of  attacks  alone  is  not  responsible  for  the  effect 
on  the  intellect,  but  the  mind  suffers  more  when  the  attacks  follow  in 
quick  succession.  Epileptics  early  suffer  changes  in  the  moral  sphere, 
in  the  affections,  the  disposition,  and  the  emotions,  before  any  intel- 
lectual decadence  is  observed.  Although  the  prognosis  is  unfavorable 
as  respects  cure,  decided  amelioration  can  be  effected  in  a  large  pro- 
portion. A  few  cases  are  cured,  and  the  number  of  cures  increases 
with  the  improvements  in  therapeutics.  The  earlier  the  treatment  is 
undertaken  the  more  favorable  the  termination.  The  less  the  number  of 
attacks  within  a  given  period  and  in  the  aggregate,  the  more  favor- 
able. If  there  be  a  distinct  peripheral  cause,  as  injury  to  a  nerve,  a 
tape- worm,  etc.,  the  prognosis  is  more  favorable  ;  but,  when  the  status 
epilepticus  is  established,  it  does  not  suffice  merely  to  remove  the  cause. 
If  central  lesions  exist,  the  termination  by  recovery  seems  quite  im- 
possible. Heredity  apparently  increases  the  intractability  of  the  dis- 
ease, but  some  notable  exceptions  have  been  published.  Nocturnal 
attacks  are  less  amenable  to  treatment  than  diurnal.  The  forms  of 
epilepsia  mitior  are,  as  a  rule,  more  difficult  to  manage  than  epilepsia 
gravior.  Absence  especially  has  disastrous  effects  on  the  mind.  Fi- 
nally, treatment  has  an  important  influence  for  good  or  evil  over  the 
course,  duration,  and  termination  of  epilepsy  in  all  its  forms. 

Treatment. — The  success  of  the  management  of  epilepsy  depends 


g02  DISEASES  OF  THE  NERVOUS  SYSTEM. 

largely-  on  the  success  with  which  various  sources  of  peripheral  irrita- 
tion are  investigated  and  removed.  Every  case,  therefore,  requires  the 
most  deliberate  and  searching  investigation.  Has  there  been  an  in- 
jury ?  Is  it  of  the  cranium  or  of  a  peripheral  nerve  ?  Many  cases 
have  been  cured  by  the  application  of  the  trephine,  and  the  number  is 
increasing.  So  favorable  have  been  the  results  of  this  practice  that, 
if  a  severe  blow  on  the  cranium  has  been  followed  by  epilepsy,  and  any 
injury  of  the  bone  can  be  detected,  the  trephine  should  be  used.  Cica- 
trices so  situated  as  to  exercise  pressure  on  a  nerve  should  be  dissected 
out — a  practice  of  special  necessity  when  an  aura  or  any  uneasy  sensa- 
tion starts  from  the  affected  part.  If  there  be  a  defined  aura  so  situated 
as  to  be  intercepted  in  its  passage  to  the  brain,  various  expedients  have 
been  resorted  to  for  this  purpose,  as  a  ligature  about  the  thigh,  leg,  or 
arm,  the  application  of  a  blister  to  surround  the  limb,  or  the  cauteri- 
zation, by  nitrate  of  silver,  of  a  band  around  the  extremity.  Perma- 
nent relief  has  been  obtained  by  cutting  down  on  the  point  whence 
an  aura  proceeds,  and  not  only  removing  a  source  of  irritation,  but 
dividing  or  stretching  a  nerve-trunk.  When  the  impression  arises  at 
the  epigastrium  and  passes  thence  to  the  brain — probably  the  most 
frequent  of  all  prodromic  symptoms  or  warnings — most  careful  atten- 
tion must  be  given  to  the  diet.  The  author  has  witnessed  more  good 
from  a  careful  regulation  of  the  diet  than  from  any  mode  of  medica- 
tion. Epileptics  eat  largely  and  bolt  their  food.  When  stomachal 
symptoms  exist,  an  epileptic  should  be  restricted  to  the  milk-diet  for 
several  weeks,  and  should  then  gradually  have  additions  made  to  it ; 
I)ut  the  permanent  diet  should  not  exceed  milk,  eggs,  a  little  meat  once 
a  day,  a  single  vegetable,  a  very  little  bread  and  butter,  and  one  fruit. 
Restriction  to  this  plan  of  diet  will  often  effect  remarkable  improve- 
ment. If  there  be  worms  present  in  the  canal,  they  should  of  course 
be  expelled.  If  stomach  symptoms  are  present,  good  results  are  ob- 
tained from  drop-doses  of  Fowler's  solution  three  times  a  day,  from 
half -grain  doses  of  the  oxide  or  nitrate  of  silver,  or  a  suitable  quantity 
of  oxide  of  zinc.  These  remedies  are  beneficial  only  in  cases  of  epi- 
lepsy dependent  on  stomachal  derangements.  The  danger  of  staining 
by  the  use  of  silver  remedies  should  not  be  overlooked.  From  the  nega- 
tive jDoint  of  view  there  are  several  important  questions  connected  with 
the  stomach  and  alimentation.  Coffee,  tea,  tobacco  in  any  form,  and 
all  kinds  of  alcoholic  drinks,  must  be  forbidden  to  all  classes  of  epilep- 
tics. It  is  important  to  prevent  paroxysms,  since  habit  enters  largely 
into  the  mechanism  of  epileptic  seizures.  The  means  of  intercepting 
an  aura  have  been  referred  to.  Brown-Sequard  suggests  various  pe- 
ripheric irritations — pulling  on  the  great-toe,  inhaling  a  little  carbonic- 
acid  gas,  etc.  The  inhalation  of  ether  and  chloroform  may  render  the 
attacks  less  severe,  but  the  practice  is  questionable.  When  the  attacks 
are  nocturnal,  a  sufficient  dose  of  chloral,  or  better,  the  hypodermatic 


HYSTERIA.  603 

injection  of  morphia  at  bed-hour,  will  act  most  efficiently  to  prevent 
them.  The  nitrite  of  amyl  by  inhalation  will  often  avert  an  impend- 
ing attack.  The  advantage  of  this  remedy  consists  in  the  facility  with 
which  it  is  employed.  A  perl  containing  three  to  five  minims  can  be 
broken  np  in  a  handkerchief  and  inhaled  without  delay.  Nothing 
should  be  done  during  the  paroxysm  but  relieve  the  body  of  all  con- 
stricting bands,  and  put  the  epileptic  in  a  position  where  he  will  not 
injure  himself.  The  question  of  a  suitable  remedy  for  the  disease  is 
by  no  means  a  complicated  one.  There  can  be  no  question  of  the- supe- 
riority of  the  bromides,  and  notably  the  bromide  of  potassium,  over  all 
other  remedies.  Their  long-continued  use  is  attended  with  few  disad- 
A'antages,  and  the  mental  condition  improves  rather  than  declines  under 
their  employment.  The  bromides  of  sodium  and  potassium  are  chiefly 
administered,  but  the  potash  salt  is  unquestionably  more  efficient.  The 
point  to  arrive  at  in  the  course  of  the  use  of  the  bromides  is  an  anaes- 
thetic state  of  the  fauces — an  important  fact  which  we  owe  to  Voi- 
sin.  The  fauces  must  haA'e  their  reflex  sensibility  so  far  reduced 
that  no  movements  are  excited  by  touching  the  palate,  base  of  the 
tongue,  or  any  part  of  the  throat.  The  amount  required  to  produce 
this  result  will  vary,  according  to  the  individual  susceptibility,  from 
one  half  to  two  drachms  per  day,  but  it  should  be  borne  in  mind  that 
it  is  not  the  quantity  of  the  medicine  required,  but  the  effect  produced, 
which  should  guide  the  administration.  Bromism  may  be  prevented 
by  the  occasional  use  of  a  purgative,  by  maintaining  free  action  of  the 
kidneys,  and  by  combination  with  Fowler's  solution,  two  or  three  drops 
morning  and  evening.  Next  to  the  bromides  the  best  results  are  ob- 
tained from  strychnia.  Usually  the  author  has  given  strychnia  with 
the  bromides  in  cases  of  epilepsy  occurring  in  weak  and  anaemic  sub- 
jects. It  is  adapted  to  those  cases  in  which  there  is  mere  instability 
of  nervous  matter,  due  largely  to  anasmia,  and  is  contraindicated  in 
those  cases  characterized  by  exalted  reflex  excitability,  with  peripheral 
irritation.  In  the  treatment  of  epilepsy  by  bromides,  the  mistake  is 
made  of  giving  it  irregularly,  or  of  suspending  it  capriciously.  It 
should  not  be  suspended,  even  if  bromism  occur  ;  it  should  be  dimin- 
ished in  amount  and  active  elimination  set  up,  and  then  resumed  in 
the  dose  necessary  to  maintain  anaesthesia  of  the  fauces.  It  should  be 
continued  for  a  long  period  after  the  convulsions  have  ceased,  probably 
not  less  than  two  years. 

HYSTERIA. 

Deflnition. — Hysteria  is  a  functional  nervous  trouble,  characterized 
by  various  motor,  sensory,  and  intellectual  disturbances,  and  by  exces- 
sive variability  in  their  seat  and  manifestation. 

Causes. — Hysteria  is  almost  exclusively  confined  to  women,  and 
only  occasionally  witnessed  in  men.     The  sexual  condition,  the  social 


604  DISEASES   OF  THE  NERVOUS   SYSTEM. 

habits,  the  repression  which  a  very  limited  sphere  of  activity  enjoins, 
and  a  much  greater  mobility  of  the  nervous  system,  are  supposed  to 
be  the  chief  reasons  for  the  relatively  greater  prevalence  of  hysteria  in 
females.  The  age  at  which  hysterical  manifestations  appear  is  not  a 
fixed  one,  and,  although  most  frequent  from  puberty  on  for  ten  or 
more  years,  attacks  occur  from  childhood.  In  Briquet's  collection  of 
four  hundred  and  twenty-six  cases,  two  hundred  and  twenty-one  ap- 
peared between  the  twelfth  and  twentieth  years  of  life.  Undoubtedly, 
that  mobility  of  the  nervous  system,  and  instability,  on  which  the 
manifestations  of  hysteria  depend  in  the  mother,  are  transmitted  to  the 
daughter.  If  the  so-called  neurotic  type  of  constitution  is  inherited, 
in  one  generation  it  may  assume  the  shape  of  hysteria  ;  in  the  next,  epi- 
lepsy ;  and  in  the  third,  insanity.  But  the  hysterical  type,  as  such,  is 
more  directly  inheritable.  That  derangement  of  the  female  sexual 
organs — especially  of  the  uterus  and  ovaries — is  the  essential  cause  of 
hysteria,  is  an  opinion  no  longer  entertained  in  any  quarter.  It  can 
not  be  too  strongly  insisted  on  that  there  is  a  peculiar  morbid  state  of 
the  nervous  system — a  neurosis — either  inherited  or  acquired,  and  that 
various  kinds  of  disturbances  may  excite  the  morbid  manifestations. 
These  disturbances  may  be  in  the  sexual  system,  in  the  digestive,  in 
the  circulatory,  or  in  the  nervous.  This  peculiar  state  of  the  nervous 
system  may  be  acquired  by  faults  of  early  training,  by  a  lack  of  per- 
sonal discipline,  by  frequent  alternations  of  feeling,  by  moi-tification, 
chagrin,  and  other  moral  and  emotional  excitements.  That  hysteria 
may  exist  independently  of  sexual  causes  is  quite  proved  by  the  fact 
that  violent  hysterical  paroxysms  occur  in  women  congenitally  defi- 
cient, and  wanting  in  uterus,  and  ovaries,  and  all  sexual  characteristics. 
The  instability  of  the  nervous  system  belonging  to  hysteria  is  much 
increased  by  certain  physical  causes — notably  by  ansemia.  When  the 
blood  is  impoverished,  the  nervous  tissue  becomes  excessively  irritable, 
and  the  discharges  of  nervous  force  are  frequent  and  irregular,  while 
deficient  in  sustained  force. 

Pathogeny  and  Symptoms. — No  structural  alterations  have  been 
detected  in  the  centers  where  the  disturbances  of  function  exist.  Hence 
hysteria  is  properly  a  neurosis — a  functional  disorder.  The  old  notion, 
that  uterine  disease  is  a  necessary  element  in  hysteria,  as  the  word 
indicates,  has  long  been  abandoned.  The  first  manifestations  of  hys- 
teria are  usually  trivial — mere  irritability  or  mobility  of  disposition  ; 
rapid  changes  of  feeling  without  aj^parent  motive  ;  noisy  and  tempes- 
tuous transitions  of  sadness  and  joy,  tears  and  laughter.  In  the  course 
of  development,  physical  are  added  to  these  merely  psychical  changes  ; 
quick  and  unaccountable  alternations  of  cold  and  heat,  that  are  purely 
subjective,  and  felt  usually  in  the  extremities  ;  numbness,  tingling, 
and  other  altered  sensations,  which  are  extremely  irregular,  now  severe, 
awakening  fears  of  paralysis,  now  forgotten  in  the  jiresence  of  some- 


HYSTERIA.  605 

thing  interesting  to  occupy  the  attention,  access  of  suffocative  feel- 
ings, "  pain  around  the  heart,"  palpitations,  quick  breathing,  a  sense 
of  fullness  of  the  stomach,  eructations  of  gas,  and  the  rising  of  a  globe 
to  the  larynx  (globus  hystericus),  producing  a  sensation  of  choking  ; 
alternate  flushing  and  pallor  of  the  face  ;  restlessness  ;  the  whole  end- 
ing, it  may  be,  in  prolonged  laughter,  but  more  usually  in  crying,  and 
in  a  profuse  urinary  discharge,  the  urine  being  pale  and  watery.  Such 
an  attack  may  occur,  with  more  or  less  frequency,  in  a  young  woman 
of  good  health  otherwise,  and  may  never  advance  beyond  this.  In 
addition  to  the  symptoms  just  described,  there  may  be  spasmodic  phe- 
nomena, tonic  and  clonic.  When  the  more  severe  attacks  approach, 
they  exhibit  alternations  of  chilliness  and  heat,  they  yawn  and  gape  a 
great  deal,  the  limbs  are  in  a  condition  of  unrest,  of  "fidgets,"  they 
laugh  and  cry,  and  equally  without  reason,  they  urinate  frequently, 
the  heart  palpitates,  they  choke  with  a  ball  rising  up  into  the  throat 
and  gasp  for  breath,  sobbing,  and  coughing  with  a  loud,  metallic  clang, 
the  jaws  are  fixed,  the  face  retracted,  the  teeth  grinding  together,  the 
hands  clinched,  the  limbs  drawn  up  and  rigid.  Such  are  the  phe- 
nomena of  the  tonic  convulsion.  In  a  few  minutes,  usually,  or  in  an 
hour  or  tw^o,  the  attack  subsides,  the  patient  sheds  a  flood  of  tears, 
passes  a  large  quantity  of  limpid  urine,  and  goes  to  sleep  exhausted. 
In  other  cases,  a  brief  stage  of  tonic  rigidity  is  succeeded  by  irregular 
clonic  convulsions,  the  patient  throws  her  limbs  about,  screams,  tears 
at  her  throat  to  remove  the  choking  sensation,  sobs,  gives  forth  re- 
peated, loud  hiccough,  the  abdomen  is  full  of  gas,  and  there  are  loud 
borborygmi ;  sometimes  the  pelvis  is  moved  in  a  rhythmical  manner, 
and  the  limbs  are  fixed.  There  is  no  loss  of  consciousness,  the  reflex 
movements  of  the  iris  and  eyelids  are  preserved,  and,  although  the 
jaws  are  rigid,  if  fluid  reach  the  fauces  it  is  soon  swallowed,  and  the 
realization  of  surrounding  events  is  preserved.  As  a  result  of  the  vio- 
lent muscular  efforts,  the  skin,  which  was  at  first  cool,  becomes  warm 
and  perspiring.  These  convulsions  last  for  several  minutes,  or  as 
many  hours.  They  subside  in  a  flood  of  tears,  the  body  is  completely 
exhausted,  and  the  patient  sinks  into  a  deep  sleep.  During  these 
attacks,  usually,  the  reflexes  are  increased,  and  pressure  on  certain 
regions  of  the  face,  head,  or  spine,  or  on  the  ovaries,  will  increase  the 
convulsive  movements.  According  to  Charcot,  pressure  on  an  ovary 
will  excite  attacks,  and  firm  pressure  may  arrest  hystero-epilepsy.  In 
some  cases  there  are  no  convulsions,  but  the  patient  passes  into  ecstasy, 
a  condition  of  fixed  immobility  and  death-like  pallor  of  the  face,  half- 
closed  eyes,  almost  suspended  respiration,  extremely  feeble,  hardly 
distinguishable  pulse — an  appearance  of  death.  In  other  cases,  the 
condition  of  ecstasy  is  associated  with  catalepsy — in  which  the  limbs 
retain  the  position  in  which  they  are  placed.  The  duration  of  the 
cases  varies.     Instead  of  terminating,  in  a  certain  proportion  there  are 


QQQ  DISEASES  OF  THE  ^'ERVOUS  SYSTEM. 

remissions  merely,  and  hence  the  attacks  may  persist  for  several  days. 
The  critical  eTacuations  which  announce  the  end  of  the  seizure  do  not 
occur  in  the  remissions.  There  are  no  regular  periods  of  return,  except 
that  they  are  more  apt  to  be  present  during  the  menstrual  periods,  and 
do  not  occur  at  night.  If  the  moral  or  mental  state  and  the  bodily 
conditions  which  favor  the  attacks  continue  in  operation,  a  succession 
of  seizures  may  be  expected. 

Hysteria  is  associated  with  widespread  disorders  in  the  sensory, 
motor,  psychical,  and  vaso-motor  systems,  which  appear  at  the  onset 
of  the  disease  or  during  the  intervals  between  the  attacks.  The  retina 
may  be  so  sensitive  to  luminous  impressions  that  the  least  light  be- 
comes intolerable  ;  hence  it  is  that  so  often  the  hysterical  are  found  in 
dark  apartments.  Flashes  of  light  and  floating  objects  appear  before 
the  eyes  ;  more  complex  impressions  of  scenes  and  persons  are  repro- 
duced, and  hallucinations  are  perceived.  In  the  same  degree  hyper- 
esthesia of  the  auditory  is  present,  and  even  a  whisper  causes  pain, 
while  various  loud,  roaring,  subjective  noises  are  heard.  Sometimes  a 
remarkable  acuteness  of  hearing  is  developed,  and  out  of  this  may 
grow  conscious  deceptions.  The  hysterical,  like  the  insane,  may  hear 
voices,  but  the  results  differ  in  the  imjDortant  respect  that  the  former 
realize  their  origin.  The  sense  of  smell  in  the  hysterical  is  much  per- 
verted, and  they  are  acutely  sensitive  to  odors.  Remarkable  perver- 
sions of  taste  are  also  manifest.  The  hysterical  have  a  proj)ensity  for 
eating  chalk,  slate-pencils,  sealing-wax,  etc.  As  regards  general  sen- 
sibility, there  may  be  more  or  less  hypersesthesia  and  hyperalgesia, 
in  particular  spots  or  areas,  and  between  these  areas  of  angesthesia. 
Pain  is  one  of  the  most  usual  and  widely  distributed  of  the  sensory 
disturbances  in  hysteria,  and  headache  is  the  most  common  form. 
There  may  be  general  headache,  with  such  a  degree  of  hypersesthesia 
of  the  scalp  that  combing  the  hair  is  painful.  The  headache  may  be 
localized  to  a  particular  point  at  the  top  of  the  head,  or  to  one  temple, 
or  to  the  supra-orbital  ridge,  may  be  exceedingly  violent,  and  accom- 
panied by  chilliness  and  feverishness,  nausea,  vomiting,  and  constipa- 
tion. This  form  of  headache  has  been  called  clavus  hystericus.  It  is 
very  aj)t  to  come  on  at  or  about  the  menstrual  epoch.  Neuralgic  pains 
occur  in  the  mammae,  which  become  irritable  and  tender,  or  in  the 
praecordial  region,  which  are  always  referred  to  the  heart,  and  in  the 
left  side,  about  the  sixth  or  seventh  intercostal  space.  The  last-men- 
tioned pain  is  more  frequently  referred  to  than  even  the  headache. 
Hysterical  women  suffer  greatly  from  the  evolution  of  gas  in  the  in- 
testine, and  hence  colics  are  frequent.  Hypersesthesia  of  the  abdomi- 
nal wall  may  also  be  present,  and  simulate  peritonitis;  but  exquisite 
pain  is  complained  of  before  the  skin  is  touched,  and,  when  the  atten- 
tion is  withdrawn,  the  abdomen  can  be  pressed  upon  without  any  flinch- 
ing.    Gastralgia  is  a  very  iisxial  symptom  ;  emptiness,  abnormal  full- 


HYSTERIA.  607 

ness,  boulimia,  and  an  utter  disinclination  for  food,  are  among  the  very- 
contradictory  sensations.  The  presence  of  a  parasite  and  its  move- 
ments are  often  insisted  on.  An  irritable  bladder  is  a  common 
symptom.  Pain  in  the  extremity  of  the  coccyx,  or  coccydinia,  is  com- 
plained of,  usually  after  the  first  confinement,  or  from  the  results  of  a 
blow,  and  is  a  jDeculiarly  unmanageable  symptom.  The  much-debated 
spinal  irritation  is  also  an  extremely  frequent  symptom  in  cases  of 
hysteria.  It  consists  in  tenderness  and  pain  on  pressure  of  the  spinous 
processes  of  a  few  vertebrae,  or  of  the  parts  immediately  adjacent. 
Spinal  irritation  has  no  more  importance  than  any  of  the  pains  which 
occur  in  the  course  of  hysteria.  The  joints  are  similarly  affected,  es- 
pecially the  knee,  which  becomes  painful  and  swollen  the  more  the 
attention  is  fixed  on  it.  This  affection,  first  described  by  Sir  Benja- 
min Brodie,  is  known  as  the  hysterical  joint.  The  peculiarity  of  it  is 
the  occurrence  of  pain  and  swelling  rather  around  than  in  the  joint, 
but  often  the  joint  is  simply  rigid  in  a  position  of  flexion.  Extensive 
spots,  entirely  anaesthetic,  occur  in  hysterical  subjects.  Analgesia 
may  be  jDresent  to  such  a  degree  that  extensive  injuries  can  be  in- 
flicted without  consciousness  of  pain.  The  anaesthesia  may  be  limited 
to  one  side — hemiansesthesia.  The  muscular  sense  and  the  apprecia- 
tion of  weight  may  be  lost,  and  the  senses  of  touch  and  temj)erature 
retained.  Amblyopia  may  be  the  result  of  anaesthesia  of  the  retina. 
Paralyses  in  the  course  of  hysteria  are  numerous  and  perplexing. 
Dysphagia  may  exist  from  paralysis  of  the  pharynx,  aphonia  from 
paralysis  of  the  vocal  cords,  and  both  may  occur  on  the  instant,  and 
disappear  as  suddenly.  Paralysis  of  the  bladder  and  retention  of  urine, 
requiring  the  catheter,  is  a  common  symptom  of  hysteria.  Paralysis 
of  a  member,  of  several,  or  of  muscular  groups,  known  as  hysterical 
paralysis,  assumes  various  characters  :  one  extremity  may  be  affected, 
or  one  upper  and  one  lower  extremity  on  opposite  sides  ;  it  may  take 
the  form  of  hemiplegia,  of  paraplegia,  or  all  four  extremities  may  be 
affected  simultaneously.  It  may  be  partial  or  complete  ;  it  may  come 
on  gradually,  or  appear  suddenly  after  a  fit,  or  without  any  reason. 
The  electric  reaction  is  normal,  unless  the  limbs  are  wasted  from  long 
disuse.  There  may  be  anaesthesia  with  the  paralysis,  but  not  neces- 
sarily, and,  when  that  is  the  case,  the  electro-sensibility  is  wanting. 
On  this  Duchenne  founded  a  distinction  between  hysterical  and  other 
forms  of  paralysis,  but  incorrectly  so,  since  in  some  the  sensibility  is 
normal  or  even  increased.  The  duration  of  hysterical  paralysis  is 
very  variable  ;  it  may  continue  for  a  few  hours,  a  few  days,  many 
months,  or  several  years,  and  it  may  unexpectedly  disappear  from  one 
part  to  attack  another.  With  or  without  palsy  there  may  be  contrac- 
tion, or  after  the  paralysis  has  existed  for  some  time  the  contraction 
may  come  on.  In  the  upper  extremity,  a  spasmodic  flexion  of  the  fin- 
gers, hand,  or  forearm  may  occur  ;  in  the  lower,  spasmodic  extension 


g08  DISEASES   OF   THE   NERVOUS  STSTEil. 

of  the  hip,  knee,  and  ankle-joints.  The  behavior  of  the  contractions 
is  the  same  as  the  paralysis — they  continue  a  variable  period,  to  be 
suddenly  terminated  by  some  moral  influence.  Various  disturbances 
ensue  in  the  realm  of  the  vaso-motor  nervous  system — irregularity  and 
weakness  in  the  heart's  action  ;  amenorrhoea  and  dysmenorrhoea  ;  ej)is- 
taxis,  haemoptysis,  and  hsematemesis  ;  stigmatizations.  As  extraor- 
dinary ingenuity  and  perseverance  and  self-denial  are  employed  to 
execute  the  deceptions  by  which  they  produce  the  appearance  of  these 
maladies,  to  excite  sympathy  and  attention,  the  physician  must  be 
on  his  guard  lest  he  be  led  into  error.  Remarkable  mutilations  and 
personal  injuries  are  effected,  to  excite  sympathy  or  wonder  in  those 
about  them.  Influenced  by  a  morbid  craving  for  strange  excitements, 
an  hysterical  girl  will  injure  an  infant,  burn  a  house,  stick  things  un- 
der the  skin,  drink  her  urine  to  make  believe  that  none  has  passed, 
produce  pins  as  having  come  from  the  bladder,  or  draw  a  dead  animal 
from  the  vagina,  etc.  Indeed,  there  is  scarcely  a  limit  to  the  extraor- 
dinary fancies  or  to  the  eccentric  acts  of  the  hysterical.  Besides  these 
perverse  and  singular  acts,  growing  out  of  moral  perversion,  the  hys- 
terical may  undergo  forms  of  mental  derangement,  the  most  persistent 
ending  their  days  in  asylums.  In  some,  the  mental  disorder  takes  the 
place  of  melancholia,  and  they  tend  to  injure  others,  or  to  the  com- 
mission of  suicide,  to  give  vent  to  their  notions  of  misery.  In  others, 
the  disorder  is  in  the  direction  of  moral  mania  :  they  steal,  injure  arti- 
cles of  clothing,  or  set  fire  to  the  house  ;  they  are  given  to  sexual 
vices,  to  strong  drink,  and  are  utterly  without  a  moral  sense.  In 
others,  there  will  be  developed  mania  with  delusions,  often  of  a  re- 
ligious kind. 

Course,  Duration,  and  Termination. — Beginning  often  at  a  com- 
paratively early  period,  hysteria  reaches  its  highest  development  from 
puberty  to  thirty-five,  afterward  decreasing,  to  disajjpear  in  old  age. 
Those  developing  slowly  under  hereditary  influence  and  by  example 
are  the  most  difficult  to  cure.  In  that  admirable  little  book,  "  Fat  and 
Blood,"  Mitchell  describes  with  a  master  hand  the  course  of  many 
cases  :  "  But  no  matter  how  it  comes  about,  the  woman  grows  pale 
and  thin,  eats  little,  or  if  she  eats  does  not  profit  by  it.  Everything 
wearies  her — to  sew,  to  write,  to  read,  to  walk — and  by  and  by  the 
sofa  or  the  bed  is  her  only  comfort.  Every  effort  is  paid  for  dearly, 
and  she  describes  herself  as  aching  and  sore,  as  sleeping  ill,  and  as 
needing  constant  stimulus  and  endless  tonics.  Then  comes  the  mis- 
chievous role  of  bromides,  opium,  chloral,  and  brandy.  If  the  case  did 
not  begin  with  uterine  troubles,  they  soon  appear,  and  are  usually 
treated  in  vain  if  the  general  means  employed  to  build  up  the  bodily 
health  fail,  as  in  many  of  these  cases  they  do  fail.  The  same  remark 
applies  to  the  dyspepsia  and  constipation  which  further  annoy  the 
patient  and  embarrass  the  treatment.     If  si;ch  a  person  is  emotional, 


HYSTERIA.  609 

she  does  not  fail  to  become  more  so,  and  even  the  firmest  women  lose 
self-control  at  last  under  incessant  feebleness.  If  no  rescue  comes,  the 
fate  of  the  woman  thus  disordered  is  at  last  the  bed.  They  acquire 
tender  spines  and  furnish  the  most  lamentable  examples  of  all  the 
strange  phenomena  of  hysteria."  Under  the  influence  of  marriage 
and  child-bearing,  the  hysterical  troubles  may  disappear  entirely  or 
for  a  long  period,  returning  from  time  to  time,  but  much  less  severely. 
In  most  cases  there  are  remissions  and  exacerbations,  and  those  cases 
characterized  by  the  most  severe  symptom  may  have  the  shortest 
duration.  The  danger  to  life  is  inconsiderable.  The  probability  of 
mental  disorder  arising  is  slight,  but  the  prospect  of  cure  is,  in  the 
cases  of  long  duration,  very  remote  and  uncertain. 

Diagnosis. — The  diagnosis  of  hysteria  rests  on  the  age,  sex,  the 
variability  and  diffusion  of  the  symptoms.  There  is  no  possibility  of 
mistaking  an  attack  of  vapors.  Epilepsy  is  distinguished  from  the 
convulsions  of  hysteria  in  the  order  with  which  the  several  stages  occur, 
in  the  loss  of  consciousness  and  the  abolition  of  reflex  movements,  biting 
the  tongue  or  cheek,  the  after-coma,  and  in  the  absence  of  hysterica 
phenomena  in  the  interval.  In  those  cases  of  epilepsy  occurring  in 
hysterical  women,  there  may  be  no  points  of  difference,  when  it  may 
be  assumed  that  the  two  maladies  occur  together.  Hystero-epilepsy 
presents  some  remarkable  features,  especially  as  regards  the  condition 
of  tonic  rigidity,  so  that  it  must  always  be  readily  recognized.  The 
influence  of  pressure  on  the  ovaries  and  the  singular  history  in  these 
cases  will  contribute  to  the  facility  of  diagnosis.  Hysterical  palsies 
of  every  kind  are  distinguished  by  the  preservation  of  the  electro-con- 
tractility, and  the  occasional  absence  of  electro-sensibility,  by  the  ab- 
sence of  all  trophic  disturbances,  and  by  the  history  of  hysterical  trou- 
bles of  various  kinds.  In  hysterical  hemiplegia  there  is  no  facial 
paralysis,  and  no  apoplectic  seizures  precede  the  hemiplegia. 

Treatment. — In  this  malady,  above  all  others,  are  moral  and  hy- 
gienic measures  of  most  importance.  "When  the  hysterical  constitution 
is  inherited,  prophylactic  methods  should  be  pursued  from  an  early 
period.  Self-control  should  be  instilled  into  the  mind  from  the  first 
dawn  of  intelligence,  and  the  muscular  and  digestive  systems  should 
be  cultivated,  while  the  nervous  is  trained  to  subordination.  Early 
hours,  substantial  food,  plain  clothing  adapted  to  the  needs  of  the 
body,  should  be  insisted  on,  while  society,  the  follies  of  dress  and 
fashion,  and  dainties,  should  be  prohibited.  The  utmost  care  is  neces- 
sary in  the  selection  of  books  for  young  ladies.  The  modern  novel 
has  done  much  mischief  by  cultivating  morbid  fancies  and  false  notions 
of  the  relation  of  the  sexes,  etc.  Sexual  abuses,  although  less  influ- 
ential than  usually  supposed  to  be,  do  have  an  injurious  effect  on  the 
nervous  system.  If  the  hysterical  condition  develops  in  spite  of  the 
precautions  advised,  remedial  measures  become  necessary.  The  con- 
39 


610  DISEASES   OF  THE  NERVOUS  SYSTEM. 

dition  of  ansemia  must  be  removed  by  cbalybeates,  a  generous  diet, 
and  suitable  exercise.  Those  tonics  are  most  suitable  which  have  a 
special  direction  to  the  nervous  system,  as  arseniate  of  iron,  strychnia, 
and  the  phosphates.  As  the  opposite  condition  or  plethora  may  exist, 
although  less  common  than  ansemia,  iron,  arsenic,  and  strychnia  should 
be  avoided,  and  such  remedies  as  the  bromides,  gelsemium,  and  cimi- 
cifuga  prescribed.  For  simple  hysterical  seizures  without  convul- 
sions, the  elixir  of  valerianate  of  ammonia,  a  camphor  julep,  a  little 
fluid  extract  of  valerian,  or  a  few  drops  of  Hoffman's  anodyne,  repeated 
every  few  minutes,  will  terminate  the  seizure.  In  the  convulsive  form, 
as  the  trismus  is  difficult  to  overcome,  inhalations  of  amyl  nitrite  or 
of  ether  may  be  practiced,  rectal  injections  of  turpentine,  ammoni- 
ated  valerian,  tincture  of  asafoetida,  or,  in  violent  cases,  a  minute 
quantity  {^  gr.)  of  morphia,  hypodermatically,  may  be  adminis- 
tered. For  the  various  complications  of  hysteria  the  resources  of  the 
therapeutist  are  severely  tried.  Migraine  or  clavus  may  be  cured  by 
attention  to  the  general  health,  and  by  such  remedies  as  guarana,  coca, 
nux  vomica,  arsenic,  aconitia,  galvanism,  etc.  Hysterical  aphonia  and 
dysphagia  may  sometimes  be  cured  instantly  by  faradic  applications. 
Anaesthesia  is  most  successfully  treated  by  the  electric  brush,  a  strong 
current  being  applied  after  drying  the  part  well.  The  various  forms 
of  hysterical  paralysis  require  faradic  applications.  A  single  appli- 
cation may  overcome  paralysis  of  long  standing,  especially  if  the  im- 
pression made  by  the  electricity  is  seconded  by  tact  and  moral  force 
on  the  part  of  the  physician.  Mitchell  has  devised  a  plan  of  treatment 
for  bed-fast  hysterical  subjects  which  seems  very  successful.  It  consists 
in  the  combined  use  of  massage,  faradizations,  and  forced  feeding. 
Massage  consists  in  friction,  kneading  and  tapping  of  all  the  muscles 
except  those  of  the  face,  in  passive  motions  of  all  the  joints,  and  in 
muscular  motions  produced  by  faradic  applications.  The  frictions  are 
made  with  lard  or  cacao-butter.  The  diet  consists  at  first  of  milk  only, 
but  additions  are  made  to  it  from  time  to  time,  until  ultimately  the 
feeding  is  very  liberal.  No  exercise  is  allowed,  but  all  movements  are 
made  for  the  patient,  which  is  exercise  without  voluntary  effort.  Re- 
markable gain  in  weight  takes  place,  and  when  the  improvement 
reaches  a  certain  point  systemic  voluntary  exercise  is  begun.  An  im- 
portant point  in  Mitchell's  treatment  is  the  separation  of  the  patient 
from  all  her  former  associations  and  the  superabundant  sympathy  of 
home.  She  is  placed  in  charge  of  a  nurse,  on  a  diet  of  milk  ;  hunger 
takes  the  place  of  her  indifference  to  food.  She  is  placed  in  bed,  and 
not  permitted  to  move  ;  the  desire  for  action  grows  out  of  the  utterly 
monotonous  idleness.  She  is  acted  on  by  the  electrical  force,  and  by 
the  moral  force  of  her  new  environments,  and  stimulated  to  wise  think- 
ing by  the  ingenious  suggestions  of  an  acute-minded  physician.  The 
result  is  she  is  cured. 


CATALEPSY.  gH 


CATALEPSY. 


Definition. —  Catalepsy  is  applied  to  a  state  with  or  without  loss  of 
consciousness,  in  which  the  cerebral  functions  are  in  a  state  of  sus- 
pension, and  the  voluntary  muscular  system  in  a  position  of  fixed 
rigidity. 

Pathogeny  and  Symptoms. — Catalepsy  rarely  occurs  as  an  indepen- 
dent affection,  and  is  usually  associated  with  certain  kinds  of  mental  dis- 
order— with  ecstasy,  hysteria,  and  somnambulism.  Young,  impression- 
able, and  nervous  subjects  are  particularly  liable  to  it.  The  attacks 
occur  suddenly,  and  are  not  indicated  beforehand  by  striking  phe- 
nomena. It  is  true  that  prodromes  may  occur  ;  there  may  be  changes 
in  the  feelings — sadness,  unexpected  gayety,  a  state  of  apprehension — 
or  actual  j)ain,  headache,  and  general  muscular  soreness  may  be  felt,  or 
vertigo,  yawning,  gaping,  a  condition  of  unrest,  may  come  on  ;  but  these 
sensations  are  neither  necessary  nor  constant.  The  patient  is  attacked, 
in  what  position  soever  at  the  time,  as  if  petrified,  but  there  is  no  muscu- 
lar relaxation  ;  on  the  contrary,  there  is  a  state  of  tonic  rigidity,  the  an- 
tagonistic muscular  groups  acting  with  equal  tension.  The  conscious- 
ness is  abolished  in  the  sense  that  all  exterior  objects  have  vanished, 
and,  although  impressions  may  be  received,  they  produce  no  reactions. 
While  the  mind  is  in  abeyance,  the  muscular  system  is  in  a  condition 
of  tonic  spasm,  resisting  passive  motion  and  over  which  no  voluntary 
control  is  exerted,  and  the  muscles  are  suddenly  fixed  in  the  position 
in  which  they  were  when  the  seizure  came  on,  as  if  set  in  stone.  Al- 
though the  muscles  are  not  acted  on  by  the  will,  they  afterward  sub- 
mit to  passive  motion,  and  remain  in  any  position  in  which  they  are 
placed.  But  little  resistance  is  then  opposed  to  passive  motion  ;  the 
members  are  perfectly  flexible,  and  yet  when  fixed  in  a  certain  posi- 
tion remain  immobile,  and  without  trembling  or  vibrating.  The  limbs 
mav  be  put  into  the  most  odd  and  uncomfortable  attitudes,  and  main- 
tain them  against  gravity  for  some  time,  but  the  muscles  at  length 
begin  to  tremble  and  ultimately  yield  according  to  gravity.  The 
appearance  of  the  patient  is  very  peculiar,  sitting  or  standing  immo- 
bile in  a  fixed  attitude,  staring  straight  forward  and  upward,  the 
countenance  pale  and  rigid,  breathing  scarcely  perceptible,  the  pulse 
small  and  weak.  On  touching  the  conjunctiva,  there  are  faint  move- 
ments of  the  eyelids  ;  and,  if  articles  of  food  are  placed  well  back  into 
the  pharynx,  swallowing  is  induced,  but  the  organic  like  the  voluntary 
movements  are  performed  imperfectly.  There  may  be  entire  abolition 
of  the  sensation  of  touch,  of  pain,  and  of  reflex  movements  ;  but  in 
other  cases  the  patients  have  a  partial  knowledge  of  events  transpir- 
ing during  the  seizures,  and  in  a  few  instances  hyperaesthesia  has  been 
noticed.  During  the  attack,  the  surface  is  cold,  and  the  temperature 
.falls.     When  the  paroxysm  ends,  the  patient  suddenly  rouses,  takes  a 


612  DISEASES  OF  THE  NERVOUS  SYSTEM. 

deep,  sighing  inspiration,  yawns  widely,  and  gapes  loudly,  as  if  wak- 
ing from  a  profound  and  protracted  sleep. 

Course,  Duration,  and  Termination. — The  attacks  of  catalepsy  vary 
in  frequency  and  severity.  They  may  last  a  few  minutes,  several 
hours,  or  for  days.  There  is  no  regulaiity  in  the  appearance  of  the 
attacks,  and  in  the  interval  the  patient  may  have  good  health,  but  usu- 
ally suffers  from  hysteria.  After  the  first  attacks,  the  patient  may  at 
once  resume  her  ordinary  occupation,  but  repeated  recurrences  set  up 
a  pathological  condition  of  the  nervous  system,  exhibited  in  the  various 
phenomena  of  neurasthenia.  As  catalepsy  is  associated  with  certain 
forms  of  mental  derangement,  it  is  probable  that  its  appearance  may 
sometimes  indicate  the  occurrence  of  such  mental  disorder. 

Treatment. — Only  the  protracted  cases  require  attention  during  the 
paroxysm.  Those  cases  which  continue  for  days  require  alimentation 
by  forced  measures.  The  food  may  be  placed  well  back  into  the 
pharynx,  or  liquids  may  be  introduced  through  an  oesophageal  tube 
passed  by  the  nares.  A  few  minims  of  amyl  nitrite  inhaled  may  suffice 
to  stop  the  paroxysm,  and  the  hypodermatic  injection  of  morphia  may 
be  equally  as  effective.  The  usual  antispasmodics — as  asafoetida,  vale- 
rian, camphor,  turpentine — may  be  employed  by  the  stomach  or  rectum. 
The  most  important  measures  are  the  prophylactic,  to  prevent  the  re- 
turn of  the  seizures  by  improving  the  tone  of  the  nervous  system.  In 
anaemic  cases,  iron,  the  phosphates,  and  quinia,  are  the  most  appropri- 
ate remedies.  Change  of  scene,  agreeable  variety,  occupation  affording 
the  mind  entertaining  employment,  are  very  conducive  to  the  mental 
and  moral  stamina  of  such  subjects.  Electricity  may  be  employed  for 
the  double  purpose  of  arousing  patients  from  the  cataleptic  state  and 
for  im^Droving  the  tone  of  the  nei'vous  system.  The  methods  of  treat- 
ment applicable  in  hysteria  are  also  useful  in  catalepsy. 

PARALYSIS   AGITANS. 

Definition. — Paralysis  agitans,  or  shahing  palsy ,  is  muscular  tremor 
occurring  with  loss  of  power,  the  subject  of  the  disease  being  advanced 
in  life. 

Causes. — Although  rarely  seen  under  forty  years  of  age,  it  does 
occur  earlier,  Duchenne  having  met  with  a  well-marked  example  in  a 
man  of  twenty.  The  two  sexes  are  about  equally  affected.  Heredity 
is  apj)arently  not  concerned  in  its  propagation.  The  principal  causes, 
besides,  probably,  a  peculiar  state  of  the  nervous  system,  are  strong 
emotion,  fright,  grief,  anxiety  and  similar  moral  impressions.  Expos- 
ure to  cold  and  dampness  for  a  lengthened  period,  injury  to  periph- 
eral nerves  of  an  irritative  kind,  are  supposed  to  cause  the  disease 
sometimes.  It  is  said  to  be  more  frequent  in  the  Anglo-Saxon  race 
(Charcot). 


PARALYSIS  AGITANS.  gl3 

Pathological  Anatomy. — In  a  certain  projiortion  of  cases,  not  defi- 
nite, however,  no  lesions  of  any  kind  have  been  discovered  on  post- 
mortem examination.  In  other  cases,  induration  (sclerosis)  of  the  pons, 
medulla,  tubercula  quadrigemina,  and  lateral  columns  of  the  cervical 
cord,  has  been  discovered,  but  Charcot,  with  justice,  doubts  the  rela- 
tion of  the  lesions  to  the  symptoms.  In  a  third  group,  the  lesions  of 
disseminated  sclerosis  have  been  confounded  with  those  of  paralysis 
agitans.  A  consideration  of  these  facts  renders  it  evident  that  this 
disease  is  a  neurosis,  a  functional  disorder. 

Symptoms. — In  the  largest  number  of  cases,  paralysis  agitans  comes 
on  slowly,  a  slight  jerking  occurring  in  a  thumb,  hand,  or  foot — in  flex- 
ion of  the  thumb  and  finger,  pronation  and  supination  of  the  forearm. 
Any  effort  of  the  will,  as  grasping,  writing,  or  walking,  will  stop  the 
irregular  motions.  The  trembling  follows  a  certain  order  in  its  prog- 
ress from  the  point  of  beginning.  If,  for  example,  the  right  hand  is 
first  attacked  by  trembling,  after  some  months  or  years,  the  right  foot 
will  become  affected,  then  the  left  hand,  next  the  left  foot.  Rarely  is 
the  middle  line  crossed,  but  sometimes  this  occurs  :  the  right  hand 
first  attacked,  the  next  is  the  left  foot.  The  tremors  are  often  con- 
fined to  one  side  of  the  body  for  a  long  time — hemiplegic  type  ;  less 
frequently  to  both  lower  extremities — paraplegic  type.  The  head  is 
generally  unaffected.  In  some  exceptional  cases,  a  feeling  of  fatigue, 
or  neuralgic  pains,  precede  for  some  time  the  trembling,  and  are  ex- 
perienced in  the  same  limb,  which  is  subsequently  attacked  by  tremors. 
Sometimes  the  disease  sets  in  abruptly,  in  consequence  of  some  sudden 
shock,  and  may  then  affect  one  member  or  attack  them  all  simultane- 
ously. In  what  way  soever  the  disease  began,  the  symptoms  of  this 
initial  period  continue  from  one  to  three  years,  and  then  pass  into  the 
period  of  fixed  intensity.  When  complete  in  its  development,  all  the 
members  invaded,  the  trembling  becomes  almost  incessant,  but  it  is 
not  equally  severe  at  all  times.  Mental  emotion  and  exercise  increase 
the  trembling,  and  there  are  periods  of  exacerbation  without  any 
apparent  reason,  and  sleep  and  chloroform  narcosis  suspend  it.  The 
trembling  consists  in  successive  jerks — muscular  contraction  and  rel- 
axation ;  and  in  the  hand  sometimes  the  thumb  and  fingers  assume  a 
position  and  movement  like  the  rolling  of  a  pill-mass.  The  head  and 
neck  are  not  affected.  The  muscles  of  the  face  are  motionless,  the 
countenance  fixed  and  stolid,  the  muscles  of  the  jaws  are  unaffected, 
and  there  is  no  nystagmus  or  oscillations  of  the  eyes.  The  tongue  is 
somewhat  trembling,  the  lips  are  compressed,  and  speech  is  slow,  de- 
liberate, and  jerky,  as  if  the  pronunciation  of  each  word  required  a 
great  effort.  The  muscles  of  the  hand  and  of  the  neck,  body  and  ex- 
tremities, assume  a  position  of  chai'act eristic  rigidity,  preceded  by 
pains  and  cramp,  usually  supposed  to  be  rheumatic.  The  flexors  are 
first  and  most  severely  affected.     The  patient  assumes  a  characteristic 


(314  DISEASES   OF   THE   XERYOUS   SYSTEM. 

attitude,  the  body  bent  f  or-vrard,  the  neck  rigid,  making  the  vertebra 
prom  in  ens  still  more  prominent,  the  hands  flexed  and  deformed,  espe- 
cially in  the  fingers,  and  the  whole  presenting  a  strong  similarity  to 
the  joint  troubles  of  chronic  rheumatism.  Similar  deformations  occur 
in  the  lower  extremities.  It  occasionally  happens  that  rigidity  and 
deformity  occur  with  the  first  appearance  of  the  trembling.  Notwith- 
standing the  trembling,  the  motor  acts  can  be  performed ;  they  are 
retarded  rather  than  feeble  (Charcot).  The  muscles  are  easily  tired 
and  the  least  effort  causes  a  strong  sense  of  fatigue.  As  a  result  of 
the  peculiar  disability  of  the  muscles,  the  subjects  of  paralysis  agi- 
tans  have  a  peculiar  gait.  They  rise  slowly  and  are  deliberate  in  start- 
ing, but,  when  under  way,  they  go  in  a  dog-trot  with  the  head  and 
body  directed  forward.  Sometimes  retropulsion  occurs.  Given  a 
little  jerk  backward,  they  run  backward  until  they  fall.  Besides  the 
feeling  of  fatigue  just  mentioned,  these  patients  suffer  from  a  variety 
of  evil  sensations.  One  of  the  most  distressing  is  the  "  fidgets,"  a  feel- 
ing of  unrest  in  the  limbs  associated  with  the  impression  of  an  irre- 
sistible necessity  for  movement.  Sensations  of  pain,  touch,  and  tem- 
perature are  normal,  but  a  subjective  sensation  of  heat  is  often  felt 
(Charcot). 

Course,  Duration,  and  Termination. — This  is  a  disease  of  very  long 
duration — it  may  be  thirty  years.  The  first  or  formative  stage  lasts 
from  one  to  three  or  four  years  ;  the  period  of  maximum  intensity 
continues  from  two  or  three  to  twenty  years.  During  this  long  time 
there  is  a  progressive  increase  in  the  symptoms,  until  finally  the 
patients  are  quite  disabled,  confined  to  the  chair  or  to  the  couch. 
The  muscles  undergo  more  or  less  fatty  change,  and  waste  a  good 
deal.  At  the  terminal  period  very  considerable  prostration  comes 
on,  the  urine  and  faeces  are  passed  involuntarily,  and  the  mind 
becomes  cloudy  and  wanders.  Just  before  death  the  trembling  may 
cease  entirely. 

Diagnosis. — Paralysis  agitans  and  disseminated  sclerosis  were  con- 
founded together,  until  Charcot  pointed  out  the  difference  between 
them,  showing  that  the  tremors  of  the  former  are  always  present, 
while  in  the  latter  they  occur  only  when  purposive  movements  are 
undertaken.  In  senile  trembling  the  head  is  chiefly  affected,  and  the 
movement  is  merely  that  of  trembling  without  the  peculiar  jerking  of 
paralysis  agitans  ;  in  the  former  there  are  not  paresis  of  the  muscles, 
stiffness,  deformity  of  the  extremities,  and  the  impulse  to  forward 
propulsion  and  to  retropulsion,  characteristic  of  the  latter.  Mercurial 
tremor  occurs  in  those  who  are  engaged  in  some  occupation  requiring 
exposure  to  the  vapor  of  mercury,  and  it  differs  from  paralysis  agitans 
in  being  purposive,  accompanied  by  troubles  of  coordination,  defects 
of  vision,  by  a  grayish-blue  line  along  the  margin  of  the  gums,  by  a 
fetid  breath,  and  sometimes  ptyalism. 


CHOREA.  615 

Treatment. — Thus  far  the  results  of  therapeutical  management 
have  not  been  encouraging.  There  are  several  remedies  that  moderate 
the  trembling — hyoscyamia  according  to  Charcot,  but  in  the  author's 
observation  no  remedy  has  acted  so  efficiently  as  gelsemium.  Ten 
drops  of  the  fluid  extract  may  be  given  three  times  a  day.  To  moder- 
ate the  retrograde  changes,  the  best  results  are  obtained  from  quinia, 
administered  occasionally — on  alternate  weeks  during  the  formative 
period — and  the  lactojjhosphate  of  lime  with  arsenic,  continued  stead- 
ily for  months  at  a  time.  Eulenberg  has  had  good  results  from  the 
hypodermatic  injection  of  arsenic,  and  Ogle  from  extract  of  physo- 
stigma.  Monobromide  of  camphor  has  appeared  useful  in  some  cases. 
The  milder  applications  of  hydrotherapy  have  done  good  in  a  few 
instances.  From  the  variety  and  diversity  of  the  remedies  recom- 
mended, it  is  apparent  that  no  plan  of  treatment  has  been  satisfactory. 
There  is  a  general  agreement  that  the  galvanic  current  is  useless. 
Eulenberg  *  says  he  has  seen  no  good  results  from  it ;  Erb's  and 
Rosenthal's  experience  is  the  same. 

CHOREA. 

Definition. — By  chorea  is  meant  a  functional  nervous  disorder,  char- 
acterized by  defects  of  voluntary  coordination,  and  by  irregular  spas- 
modic movements  in  certain  groups  of  muscles. 

Causes. — A  peculiar  mobility  and  impressionability  of  the  centers 
of  coordination  are,  doubtless,  transmitted  by  inheritance.  The  mode 
of  life,  education,  and  training  may  induce  this  unnatural  mobility. 
The  disease  usually  makes  its  appearance  about  the  second  dentition, 
or  at  the  period  of  puberty.  When  the  predisposition  exists,  various 
causes  may  excite  the  morbid  complexus.  Among  the  most  important 
of  the  causative  influences  is  rheumatism,  or  rheumatic  endo-  and  exo- 
carditis.  The  closeness  of  the  relation  is  variously  stated.  Professor 
See  is  at  one  extreme,  for  he  finds  in  one  hundi-ed  and  twenty-eight 
cases  of  chorea  sixty-four  cases  of  acute  rheumatism.  Steiner,  of 
Prague,  is  at  the  other  extreme,  for,  in  a  series  of  two  hundred  and 
fifty  cases  of  chorea,  only  four  resulted  from  acute  rheumatism.  It  is 
impossible  to  harmonize  these  observations.  According  to  the  author's 
experience,  the  proportion  of  rheumatism  to  chorea  is  about  one  to 
eight — much  more  than  Steiner's,  and  less  than  See's.  Intestinal 
worms,  sexual  abuses,  amenorrhoea,  anaemia,  and  strong  moral  emo- 
tions, are  frequent  exciting  causes,  and  to  these  must  be  added  preg- 
nancy. 

Pathological  Anatomy. — There  are  no  constant  changes  in  the  ana- 
tomical elements.  As  a  large  proportion  of  cases  recover,  it  is  proba- 
ble that  the  derangements  are  functional.  As  so  many  cases  are  com- 
*  "  Lehrbuch  der  funktionellen  Nervenkrankheiten,"  op.  cit,  p.  Yll. 


QIQ  DISEASES   OF   THE   NERVOUS   SYSTEM. 

plicated  by  endocardial  alterations,  embolic  obstruction  of  the  minute 
vessels  of  the  corpus  striatum,  or  optic  thalamus,  has  been  proposed  to 
account  for  the  morbid  phenomena.  Hughlings  Jackson  has  espe- 
cially supported  this  view.  As  emboli  have  been  discovered  in  some 
cases,  it  seems  probable  that  this  explanation  is  occasionally  true. 
But  various  changes  have  been  discovered  :  thus  Meynert  found 
changes  in  the  cerebral  cortex,  and  Elischer  has  recently  detected  nu- 
clear proliferation,  thickening  of  the  adventitia  of  the  minute  vessels, 
and  hyperplasia  of  the  neuroglia  in  the  corpus  striatum,*  Localized 
softenings  in  various  parts  of  the  cerebro-spinal  axis  have  been  no- 
ticed, but  no  relation  can  be  traced  between  such  softenings  and  cho- 
rea, except  those  situated  in  the  corpus  striatum. 

Symptoms. — A  sudden  terror  has  produced  a  fully  developed 
chorea  in  an  extremely  nervous  child,  but  usually  the  onset  of  the 
disease  is  gradual.  At  first  the  child  appears  to  have  adopted  some 
trick  or  a  grimace,  or  an  ugly  motion  of  the  shoulder  or  arm.  Then 
irregular  jactitations  become  more  common  in  the  face  and  upper 
extremities.  The  choreic  movements  may  be  limited  to  one  side  of 
the  body,  when  it  is  known  as  hemi-chorea,  or  to  the  upper  or  lower 
extremities.  In  a  severe  case  all  of  the  voluntary  muscles  of  the  body 
are  engaged  in  choreic  movements  ;  the  muscles  of  the  face  are  dis- 
torted into  endless  grimaces  ;  the  eyes  roll  (nystagmus),  and,  the 
muscles  acting  unequally,  there  is  strabismus  ;  the  tongue  is  jerked 
about  the  mouth,  so  that  speech  is  difiicult  or  unintelligible,  and  is 
sucked  into  the  throat  with  an  audible  smack  ;  the  arms  are  troubled 
by  endless  jactitations,  the  fingers  are  twisted  into  all  conceivable 
shapes,  and  writing,  using  the  knife  and  fork,  and  holding  any  object 
are  impossible  ;  walking  is  irregular,  the  legs  catch  each  other  or  trip 
over  objects ;  breathing  is  spasmodic  and  sighing  ;  the  heart's  action 
is  tumultuous,  irregular,  and  apparently  also  choreic  ;  a  soft-blowing 
murmur  may  be  audible  at  the  base,  or  a  loud,  churning  systolic  mur- 
mur, heard  with  greatest  intensity  in  the  mitral  area.  In  the  severest 
cases  the  patient  can  not  remain  in  any  position,  but  all  the  voluntary 
muscles  are  simultaneously  engaged  in  the  most  violent  and  disorderly 
movements.  The  features  are  swollen  and  bloated  ;  blood  is  seen 
about  the  teeth  ;  the  extremities  are  bruised  and  bleeding  by  the  con- 
tinual knocking  of  bony  prominences  against  the  wall,  the  bed,  or  the 
floor.  In  the  mild  cases  the  jactitations  are  occasional  and  not  severe, 
and  cease  during  the  night,  permitting  quiet  repose.  In  the  severe 
cases  only  snatches  of  sleep  are  obtained,  the  jerking  of  the  muscles 
coming  on  after  very  short  periods  of  quiet.  In  the  severest  cases  the 
jactitations  are  incessant,  and  sleep  is  impossible.  In  all  cases  of  cho- 
rea slee])  is  apt  to  be  disturbed  by  unpleasant  dreams,  and  somnambu- 

*  "  Ueber  die  Veranderungen  in  den  peripheren  Ncrven  und  in  Riickenmark  bei  Cho- 
rea Minor,"  Virchow's  "  Archiv,"  Ixi,  p.  485. 


CHOREA.  617 

lism  is  by  no  means  uncommon.  There  is  general  exaltation  of  the 
senses  of  touch  and  pain,  and  the  reflexes  are  increased.  Tenderness 
of  the  spine,  especially  of  the  cervical  and  upper  dorsal  regions,  is  a 
constant  symjitom.  Weakness  or  perversion  of  mind  is  observed  in 
all  decided  cases,  but  usually  impaired  memory,  stupidity,  irritability, 
and  morbid  impulses  have  been  observed. 

Course,  Duration,  and  Termination. — The  course  of  chorea  is  chronic 
and  continuous,  and  the  duration  of  ordinary  cases  is  from  one  to  three 
months.  Although  regarded  as  self -limited  and  tending  to  spontaneous 
recoveiy  in  two  or  three  weeks  by  some  authorities,  it  is  really  much 
influenced  as  to  its  course  and  duration  by  appropriate  treatment.  It 
may  continue  for  a  number  of  months,  for  years  in  fact,  but  this  is 
excessively  rare.  Exacerbations  and  relapses  are  very  common.  Those 
having  attacks  at  about  seven  years  of  age  are  apt  to  experience  seiz- 
ures up  to  puberty.  If  occui'ring  in  the  first  pregnancy,  it  is  apt  to 
occur  in  subsequent  pregnancies.  The  most  intractable  cases,  accord- 
ing to  the  author's  experience,  have  been  those  of  the  first  pregnancy. 
Although  the  termination  is  usually  in  health,  death  may  result  from 
the  exhaustion  due  to  the  incessant  jactitations,  want  of  food,  and  loss 
of  sleep.  The  existence  of  pregnancy  is  a  serious  complication,  for, 
besides  the  danger  of  miscarriage,  the  severity  of  the  disease  induces 
rapid  exhaustion.  Jaccoud  collected  thirty-one  cases  of  the  chorea 
of  pregnancy,  and  of  these  four  died.  After  delivery  the  convulsions 
cease,  but  very  rarely  before  delivery. 

Diagnosis. — Chorea  is  accompanied  by  such  pronounced  symptoms 
that  it  can  hardly  be  mistaken  for  any  other  disease  as  it  occurs  in  chil- 
dren. It  may  be  confounded  with  disseminated  sclerosis  which  appears 
in  young  subjects,  and  which  has  for  a  prominent  symptom  muscular 
tremor,  but  the  tremors  are  perceived  only  on  intentional  movements, 
and  cease  when  the  muscles  are  at  rest.  Furthermore,  this  disease  is 
accompanied  by  pareses  of  the  muscles  and  the  rigidity  of  extension, 
and  often  sets  in  with  an  apoplectic  attack  and  other  formidable  symp- 
toms ;  and  its  course  and  behavior  are  so  different  in  all  other  respects 
from  the  tremor,  that  the  least  attention  ought  to  pre  vent,  error.  Pa- 
ralysis agitans  differs  from  chorea  in  the  age  of  the  subject,  the  deform- 
ity of  the  hands,  the  muscular  rigidity,  the  shape  assumed  by  the 
spine,  and  the  character  of  the  gait,  and  in  the  subsequent  course  and 
termination. 

Treatment. — Excellent  results  have  been  obtained  by  a  simple  hy- 
gienic treatment — by  confinement  to  bed  in  a  darkened  and  quiet 
room,  and  careful  but  generous  alimentation.  As  moral  causes,  excite- 
ment and  bad  hygiene,  are  very  influential  in  causing  the  disease,  sup- 
plying the  patients  with  the  opposite  conditions  ought  to  effect  im- 
provement. Treated  in  this  way,  it  was  ascertained  at  Guy's  Hospital 
that  chorea  has  a  tendency  to  spontaneous  cure  in  two  or  three  weeks. 


(518  DISEASES   OF   THE   NERVOUS   SYSTEM. 

It  is  important  to  give  to  choreic  subjects  sound  sleep — to  suspend  the 
jactitations  during  ten  hours.  This  is  best  accomplished  by  the  com- 
bined use  of  morphia  and  chloral.  A  generous  diet  should  be  directed, 
and  the  utmost  quiet  and  repose  enjoined.  Any  eccentric  irritation, 
as  worms  in  the  intestines,  impacted  faeces,  elongated  prepuce,  or  sexual 
excess,  should  be  corrected.  Ansemia  requires  the  free  administration 
of  iron,  lactophosphate  of  lime,  and  strychnia.  The  remedies  to  stop 
the  choreic  movements  consist  of  the  mineral  tonic  group — arsenic, 
the  zinc  preparations,  ammoniated  copper,  and  iron  ;  of  the  vegetable 
paralysant  group,  as  suecus  conii,  gelsemium,  physostigma ;  and  the 
anodyne  group,  as  opium,  chloroform,  chloral,  bromide  of  potassium. 
Of  the  mineral  tonic  remedies  the  best  results  are  obtained  from  arsenic, 
of  which  very  large  doses  are  easily  borne.  In  some  obstinate  cases 
the  hypodermatic  injection  of  arsenic  has  achieved  successes.  In  the 
most  violent  cases  chloroform  may  be  indispensable  to  give  even  a  few 
minutes'  repose.  In  these  violent  cases,  enormous,  almost  incredible 
doses  of  morphia  were  given  by  Trousseau  with  advantage.  Mild 
cases  are  benefited  by  ether-spray  directed  against  the  spine  for  a  few 
minutes  every  day.  Galvanization  is  also  serviceable.  A  stabile  cur- 
rent, not  too  strong,  should  be  applied  to  the  spine  and  to  the  prin- 
cipal bundles  of  spinal  nerves.  Hydrotherapy,  in  the  form  of  a  wet 
pack,  and  douche  to  the  spine,  has  been  useful  in  many  cases. 


WRITER'S   ORAMP. 

Definition. —  Writer^s  cramp  is  a  faulty  term,  but  no  really  better 
designation  has  been  proposed.  It  is  intended  to  express  the  idea  of  a 
muscular  disability  produced  by  overuse  in  a  strained  position  of  cer- 
tain muscles.  It  is  called  writer's  cramp  because  so  many  cases  have 
arisen  from  this  employment.  The  same  disability  occurs  to  pianists, 
to  seamstresses,  and  some  other  employments  requiring  the  continuous 
use  of  the  same  group  of  muscles. 

Pathogeny  and  Symptoms. — There  is  not  an  actual  condition  of 
cramp  ;  the  affected  muscles  are  not  paralyzed,  and  are  equal  to  all 
other  work,  except  the  particular  duty  in  which  they  acquired  the  dis- 
ability, Duchenne  well  expresses  it  when  he  says  there  is  an  impo- 
tence in  respect  to  the  particular  position  and  movements  involved  in 
writing.  There  is  no  disorder  of  intelligence,  no  lack  of  ideas,  and 
the  motorial  apparatus  is  intact,  but  the  muscles,  so  long  and  constant- 
ly employed  in  the  prehension  of  the  pen,  the  poising  of  the  hand  and 
forearm,  and  in  the  movement  of  the  pen  (Poore  *),  become  unequal  to 
the  task.  The  growth  of  the  disability  is  slow.  Fatigue  in  the  much 
used  muscles,  pain  in  the  forearm,  in  the  wrist,  and  in  the  hand,  are 

*  "The  Practitioner"  (London),  1879. 


WRITER'S   CRAMP.  QIQ 

experienced.  So  strong  is  the  sense  of  fatigue,  and  it  may  be  pain  in 
the  arm,  that  rest  is  often  taken  ;  the  arm  is  steadied,  and  the  pen  is 
seized  with  a  firmer  grip.  Other  muscles  are  called  into  action,  and 
great  efforts  are  made  to  relieve  the  fatigued  muscles  by  wi'iting  with 
the  whole  arm.  The  writing  changes  its  character  and  becomes  irreg- 
ular ;  the  muscles  of  the  first  three  fingers,  after  a  time,  are  given  to 
fibrillary  trembling.  Finally  writing  becomes  impossible  ;  the  pen  is 
taken  up,  a  strong  effort  of  the  will  tries  to  force  the  muscles  to  the 
task,  but  they  obstinately  refuse  to  execute  the  necessary  movements. 
In  a  perfectly  normal  state,  writing  is  so  constantly  and  for  such  a  long 
period  carried  on,  that  the  supervision  of  the  higher  centers  over  the 
muscular  movements  ceases  to  be  exercised  :  in  other  words,  the  act  of 
writing  becomes  largely  automatic.  When  such  a  muscular  disability 
occurs,  the  attention  must  be  again  directed  to  the  act,  and  then  a  new 
element  of  discord  is  introduced.  Besides  fibrillary  trembling,  a  con- 
dition of  tonic  spasm  seizes  the  muscles  of  the  thumb  and  the  flexors 
of  the  fingers.  These  involuntary  contractions  or  spasms  of  the  mus- 
cles sometimes  also  involve  the  extensors,  and  thus  a  condition  of 
ataxia  results.  There  is  still  another  group  of  cases  in  which  a  marked 
paresis  or  weakness  of  the  flexors  of  the  thumb  and  fingers  takes  place, 
and  fibrillary  trembling  frequently  coincides  with  the  weakness.  This 
group  is  called  the  paralytic  form.  There  is  still  another  group  in 
which  the  flexors  and  extensors  are  occupied  by  cramps,  there  is  no 
trembling,  no  sense  of  fatigue,  and  the  sensibility  is  intact.  In  the 
paralytic  group  the  electro-sensibility  and  the  electro-contractility  are 
reduced  ;  in  the  spasmodic  group,  the  electro-sensibility  and  contrac- 
tility are  either  exaggerated  or  normal. 

Course,  Duration,  and  Termination. — The  course  of  writer's  cramp 
is  very  chronic  and  the  duration  indefinite.  It  is  more  often  than 
is  supposed  the  precursor  of  more  serious  ailments  of  the  nervous 
system.  If,  with  the  first  symptoms,  entire  rest  be  given  to  the 
affected  member,  a  cure  may  be  readily  effected  ;  but,  when  the 
disability  is  complete,  the  prognosis  as  to  cure  is  very  gloomy.  If 
it  be  true,  as  the  author's  observation  has  led  him  to  conclude,  that 
writer's  cramp  is  often  followed  by  other  nervous  diseases,  no  case 
is  without  importance,  and  the  management  should  include  instruc- 
tions as  to  manner  of  life  and  regimen,  to  avoid  future  complica- 
tions. 

Treatment. — As  soon  as  the  symptoms  of  writer's  cramp  become 
manifest,  writing  should  be  relinquished  immediately,  and  the  muscles 
be  given  rest  for  several  months.  Rest  may  remove  all  the  symptoms, 
and  subsequently  moderation  in  the  amount  of  writing  and  giving 
sufiicient  intervals  of  rest  will  entirely  obviate  the  tendency  to  cramp 
or  paresis.  Much  attention  should  be  given  to  the  position  of  the 
fingers,  and  to  the  amount  of  effort  necessary.     A  large  pen-holder 


620  DISEASES   OF   THE   NERTOUS   SYSTEM. 

and  an  easy,  unembarrassed  naanner  of  grasping  the  pen  are  of  much 
importance.  When  the  case  is  complete,  and  writing  becomes  impos- 
sible, a  cure  is  not  to  be  hoped  for  ;  but  such  amelioration  may  be 
effected  as  to  permit  a  very  little  daily  use  of  the  hand  in  writing. 
There  are  two  local  remedies  of  real  value — galvanism  and  massage. 
A  current  from  ten  to  fifteen  of  Siemens  and  Halske  should  be  passed 
daily  for  a  few  minutes  through  the  affected  muscles.  If  spasm  and 
faticrue  are  the  conditions  of  the  muscles,  a  stabile  current  is  to  be  pre- 
ferred ;  if  the  muscles  are  weak,  a  labile  current  should  be  used.  The 
forearm,  the  muscles  of  the  thumb,  and  the  interossei  should  be  gently 
rubbed  and  kneaded  for  a  few  minutes  previously  to  the  application 
of  electricity.  If  the  general  health  is  depressed,  good  effects  are 
obtained  from  strychnia  ;  but  this  agent  does  harm  if  the  nervous  sys- 
tem is  excitable  and  the  circulation  active.  The  phosphates,  quinia, 
and  cod-liver  oil,  should  be  prescribed  if  the  health  is  poor. 


TETANUS. 

Definition. — By  tetanus  is  meant  a  disease  characterized  by  parox- 
ysmal tonic  contractions  of  the  voluntary  muscles,  and  due  to  an  exal- 
tation of  the  reflex  function  of  the  spinal  cord. 

Causes. — Tetanus  may  be  produced  by  intrinsic  or  central  lesions 
and  extrinsic  or  peripheral  lesions.  The  latter  are  more  important  than 
the  former.  As  the  best  example  of  a  tetanic  condition  due  to  cen- 
tric causes  may  be  mentioned  the  action  of  those  agents  which  increase 
the  reflex  excitability  of  the  spinal  cord,  namely,  strychnia,  brucia,  and 
thebaia.  The  extrinsic  causes  are  wounds  and  injuries  of  various 
kinds,  especially  those  involving  nerves,  many  of  which  are  insignifi- 
cant— for  example,  the  prick  of  a  needle,  the  extraction  of  a  tooth,  per- 
forating the  ears  for  ear-rings,  or  bleeding — each  of  which  has  caused 
tetanus.  Internal  traumatic  injuries  may  produce  the  same  result. 
Tetanus  has  followed  parturition  and  uterine  diseases  ;  and  the  so- 
called  idiopathic  tetanus  has  supervened  upon  inflammatory  exuda- 
tions, involving  the  pneumogastric  or  phrenic  nerves.  The  severity 
of  the  injury  bears  no  relation  to  the  frequency  or  violence  of  the 
attacks.  When  a  wound  is  cicatrizing,  tetanus  is  more  apt  to  occur, 
especially  if  the  cicatrix  is  so  situated  as  to  compress  a  nerve.  The 
situation  of  a  wound  has  more  influence — those  of  the  extremities  hav- 
ing the  greatest  effect.  Trismus  neonatorum,  tetanus  of  the  new- 
born, occurs  usually  from  the  fifth  to  the  twelfth  day,  and  is  attributed 
to  section  of  the  funis  and  a  subsequent  inflammation.  Tetanus  also 
succeeds  to  circumcision.  Much  influence  is  ascribed  to  cold  by  some 
writers.  It  is  probably  true  that  wounded  men,  exposed  to  cold,  are 
more  liable  to  the  disease.  The  free  use  of  cold  water  as  a  dressing 
for  wounds,  during  the  rebellion,  was  responsible  for  many  eases,  it  is 


TETANUS.  Q21 

supposed  by  competent  judges.  On  the  other  hand,  tetanus  is  a  com- 
mon malady  in  tropical  countries. 

Pathological  Anatomy. — The  changes  occurring  in  tetanus  are 
found  in  various  parts  of  the  cord,  but  chiefly  in  the  medulla  oblongata, 
in  the  lumbar  region,  in  the  gray  substance  around  the  central  canal, 
and  in  the  anterior  horns.  Very  considerable  dilatation  of  the  vessels 
is  always  found.  Exudation  of  a  semi-fluid,  colloid  substance,  hyper- 
plasia of  the  neuroglia,  and  abundant  nuclear  proliferation  in  the  gray 
matter,  have  been  observed  in  the  more  recent  microscopical  investi- 
gations. 

Symptoms. — The  onset  of  the  disease  varies  according  to  the  cause. 
When  due  to  a  wound,  there  are  changes  in  its  character  as  the  disease 
is  about  to  develop  :  the  cicatrization  ceases,  the  suppuration  presents 
a  different  aspect,  the  wound  becomes  irritable,  tender,  and  red,  and 
pains  shoot  along  toward  the  body.  When  caused  by  cold,  there  is 
chilliness,  followed  by  fever,  and  stiffness  of  the  neck  is  felt.  The 
first  manifestation  of  the  tetanic  paroxysm  is,  in  a  great  majority  of 
cases,  in  the  motor  branches  of  the  fifth,  which  innervate  the  masseters 
and  internal  pterygoids,  and  the  jaws  are  set  in  a  condition  of  rigidity. 
To  this  tetanic  fixation  of  the  jaw  is  applied  the  term  trismus.  The 
attempt  to  swallow  excites  cramp  of  the  pharynx,  and  is  therefore 
difficult  and  painful.  Next,  the  post-cervical  muscles  become  rigid, 
and  the  head  is  held  back.  The  muscles  of  the  face  now  take  a  fixed 
position,  the  lips  are  retracted,  exposing  the  teeth  ;  tiie  brow  is  cor- 
rugated, giving  to  the  countenance  a  mixed  expression  of  anguish  and 
laughter — the  risics  sardonicus.  The  muscular  rigidity  now  extends 
to  the  trunk  and  extremities,  and  hence  the  whole  body,  while  helpless, 
is  immovable  and  rigid.  As  the  spinal  muscles  are  more  tense  and 
more  powerfully  acted  on,  the  body  is  bent,  and  may  rest  only  on  the 
occiput  and  heels.  This  position  is  entitled  oj^isthotonos.  Less  fre- 
quently, the  body  is  bent  in  the  opposite  direction,  or  forward — a  po- 
sition known  as  emprosthotonos.  Still  more  rarely  the  inclination  is 
lateral,  ox  pleurosthotonos.  The  condition  of  excitation  is  not  the  same 
all  along  the  spinal  canal,  for  we  find  that  the  flexors  of  the  upper 
and  the  extensors  of  the  lower  extremities  are  comparatively  more 
active.  In  the  beginning  of  the  attack,  the  rigidity  is  not  constant, 
does  not  affect  all  the  muscles  equally,  and  may  pass  from  one  to 
another  group.  There  are  remissions  also  at  first,  during  which  there 
may  be  complete  relaxation.  But  the  paroxysms  become  more  fre- 
quent and  severe,  and  are  presently  excited  by  the  slightest  movement. 
So  exquisitely  excitable  is  the  reflex  faculty,  that  the  least  possible 
peripheral  impression  brings  on  a  spasm — a  mere  touch,  a  current  of 
air,  the  reflection  from  a  mirror  or  surface  of  water,  will  excite  it. 
At  the  moment  of  the  spasm  a  sudden  tonic  contraction  seizes  all  of 
the  voluntary  muscles,  the  face  is  horribly  distorted,  the  spine  is  bent, 


622.  DISEASES   OF   THE  NERVOUS  SYSTEM. 

the  body  resting  on  the  head  and  heels,  the  abdomen  retracted,  respi- 
ration suspended,  the  feet  incurved  and  extended,  the  hands  violently 
clinched  and  drawn  in  with  the  forearms  toward  the  body.  During 
the  convulsion  a  severe  pain  is  felt  at  the  epigastrium,  and  extends 
through  to  the  back.  The  muscles  so  violently  acted  on  are  very  pain- 
ful, and  even  rupture  of  fibers,  sometimes  of  a  muscle,  may  take  place. 
The  paroxysm  soon  reaches  its  maximum  and  then  subsides,  and  dur- 
ing the  interval  between  them  the  patient  breathes  more  easily,  and  is 
able  to  swallow  a  little.  The  frequency  with  which  the  paroxysms 
come  on,  their  violence  and  duration,  furnish  the  measure  of  the  im- 
portance of  the  case.  Some  sleep  may  be  obtained  in  the  interval 
between  the  paroxysms,  but  on  awaking  the  attacks  of  spasm  are  re- 
sumed, and  in  severe  cases  sleep  is  entirely  prevented.  Meanwhile, 
the  mental  powers  are  unimpaired,  and  sensibility  and  the  special 
senses  remain  normal.  In  a  few  instances  diminution  of  sensibility 
has  been  noted.  As  muscular  activity  is  a  great  source  of  animal 
heat,  it  is  not  surprising  that  in  this  disease  there  should  be  rise  of 
temperature.  The  fever  does  not  pursue  any  special  type,  but  at 
death  it  may  attain  to  104°  or  105°  Fahr.,  and  rise  even  higher  for  an 
hour  or  two  after  death.  Profuse  sweats  also  occur.  Respiration 
during  the  spasms  is  carried  on  by  the  diaphragm  only,  and  the  pulse 
becomes  hard  and  very  rapid.  The  voice  is  harsh,  guttural,  and  some- 
times speech  is  unintelligible.  The  mouth  is  dry,  the  saliva  viscid, 
deglutition  almost  impossible,  and  constipation  is  the  rule.  The 
urine  is  normal,  or  scanty,  usually  alkaline,  and  sometimes  contains 
sugar. 

Course,  Duration,  and  Termination. — The  course  of  tetanus  may 
be  very  acute,  or  more  protracted,  when  it  is  known  as  chronic  tetanus. 
In  the  acute  form  an  early  termination  is  caused  by  tetanic  fixation  of 
the  muscles  of  respiration.  In  the  chronic  form  the  intervals  between 
the  paroxysms  are  longer  ;  the  patient  has  an  opportunity  to  obtain 
some  sleep  and  to  take  food.  In  the  tetanus  of  the  new-born,  and  in 
toxic  tetanus,  the  duration  is  shorter  than  in  the  traumatic,  the  parox- 
ysms succeed  each  other  rapidly,  and  death  occurs  in  asphyxia.  Idio- 
pathic tetanus  is  not  so  violent,  as  a  rule,  and  the  prognosis  is  hence 
more  favorable.  Traumatic  tetanus  is  always  serious,  but  the  case 
may  be  regarded  as  more  favorable  when  the  intervals  between  the 
paroxysms  are  long  enough  to  permit  sleep  and  alimentation,  and  the 
paroxysms  are  less  dangerous  to  respiration.  The  case  is  still  more 
favorable  if,  after  the  second  day,  there  is  no  increase  in  the  number 
and  severity  of  the  paroxysms. 

Diagnosis. — Tetanus  is  distinguished  from  strychnia-poisoning  by 
the  sudden  onset  and  quick  termination  of  the  latter,  and  by  the  pres- 
ence of  a  wound  or  some  other  cause  of  the  seizure.  In  spinal  menin- 
gitis there  are  tonic  spasms  of  the  muscles,  but  the  rigidity  is  not 


TETANUS.  .        623 

paroxysmal,  and  tliere  are  no  intervals  of  entire  cessation  of  the  mor- 
bid action  ;  there  is  not  the  great  reflex  excitability  of  tetanus  and 
the  occurrence  of  cramps  on  slight  irritation  peculiar  to  that  disease, 
and  in  spinal  meningitis  the  tonic  rigidity  is  succeeded  by  paralysis. 
Hydrophobia  is  very  similar  to  tetanus,  but  it  develops  more  slowly  ; 
there  is  a  special  antipathy  to  water  and  inability  to  take  it  when  other 
articles  may  be  swallowed,  and  a  peculiar  hawking  noise  is  made,  to 
dislodge  a  little  viscid  secretion  from  the  throat,  peculiar  to  this  dis- 
ease. Trismus  may  be  limited  to  the  muscles  of  mastication,  and  may 
be  produced  by  colds  and  exposure,  but  it  is  confined  to  these  muscles 
and  does  not  become  generalized.  Those  cases  occurring  in  the  course 
of  cerebral  disease  are  also  diagnosticated  by  the  symptoms  of  such 
diseases,  which  have  no  relation  to  tetanus. 

Treatment. — Whenever  an  obvious  cause  exists  it  must  be  removed. 
If  a  wound,  splinters  of  bone  and  foreign  bodies  should  be  searched 
for ;  if  a  cicatrix,  it  should  be  dissected  out ;  if  an  injured  nerve,  it 
should  be  divided.  The  remedies  which  have  been  most  successful  are 
those  which  diminish  the  reflex  function  of  the  spinal  cord.  Bromide 
of  potassium  seems  to  have  been  the  most  successful  agent  thus  far 
employed.  It  must  be  given  in  very  large  doses — from  one  to  two 
drachms  every  four  hours,  until  the  spasms  are  decidedly  diminished, 
when  the  quantity  may  be  somewhat  reduced.  Given  early,  and  the 
effect  maintained  until  the  spasms  cease,  it  must  be  regarded  as  the 
best  remedy  in  view  of  the  large  proportion  of  cures.  Next  to  the 
bromide  is  curare,  which  acts  in  the  end-organs  of  the  nerves  and  on 
the  reflex  faculty.  This  must  be  given  hypo  dermatic  ally,  and  the 
effect  produced  must  be  the  guide.  As  curare  is  a  very  uncertain  sub- 
stance in  its  composition,  the  dose  necessary  can  only  be  determined 
by  trial,  but,  inasmuch  as  one  eighth  of  a  grain  has  been  administered 
at  a  dose,  it  will  be  prudent  to  commence  with  one  fortieth  of  a  grain, 
and  increase  it  until  some  effect  on  the  spasms  has  been  caused.  Nicotia 
has  similar  properties  and  powers,  and  has  been  used  hypodermatically 
in  tetanus  and  in  strychnia-poisoning  with  success.  The  author  has 
seen  a  very  severe  case  of  traumatic  tetanus  treated  successfully  with 
the  wine  of  tobacco.  Physostigma  and  eserine  have  been  now  em- 
ployed in  a  large  number  of  cases  and  with  excellent  results.  Eserine 
can  be  given  subcutaneously,  beginning  at  one  sixtieth  of  a  grain  and 
increasing  it  until  some  effect  is  produced  on  the  spasms.  Cannabis 
Indica  has  also  arrested  some  cases  of  tetanus,  and  is  a  very  promising 
remedy.  Too  often  these  narcotic  remedies  are  given  inefficiently. 
To  be  beneficial,  an  impression  must  be  made  on  the  spasms,  and  hence 
the  effect  and  not  the  dose  must  be  the  guide.  The  spinal  ice-bag  and 
the  continuous  current  have  proved  palliative.  Warm  baths  and  the 
vapor-bath  have  given  comfort,  and  have  exerted  a  temporary  influence 
over  the  spasms.    An  estimate  of  the  value  of  a  remedy  is  much  affected 


g24  DISEASES  OF  THE  NERVOUS  SYSTEM. 

by  the  period  at  which  it  is  administered,  for  the  longer  the  case  has 
lasted  the  more  hopeful.  The  nutrition  of  cases  of  tetanus  is  highly 
important,  and  from  the  beginning  they  should  be  carefully  fed. 
Noises  and  excitement,  every  form  of  peripheric  irritation  and  emotion 
of  all  kinds,  should  be  excluded.  As  there  is  strong  temptation  to 
use  ether  and  chloroform  freely  because  of  the  relief  they  afford,  the 
author  desires  to  caution  his  readers,  because  of  the  injury  so  often 
done  by  them. 

DISEASES  OF  THE  PERIPHERAL  NERVES— NEURITIS. 

Definition. — By  the  term  iieuritis  is  meant  inflammation  of  the 
nerve-trunks  and  its  results. 

Causes. — Wounds  and  injuries  are  the  most  frequent.  Weir  Mitch- 
ell has  collected  a  most  valuable  series  of  experiences  during  the  war 
of  the  rebellion  and  subsequently,  chiefly  of  gunshot-injuries.  A  cur- 
rent of  cold  air  directed  against  a  nerve  situated  superficially  may 
excite  an  inflammation  in  it.  Neuritis  is  also  excited  by  a  contiguous 
inflammation — as,  for  example,  the  intercostal  nerves  are  inflamed  by 
extension  of  the  process  from  the  pulmonary  organs. 

Pathological  Anatomy. — The  first  step  in  the  process  is  hyperse- 
mia  :  exudation  takes  place  into  the  nerve,  which  becomes  softened, 
and  ultimately  breaks  down  into  a  diffluent  mass.  Migration  of  white 
corpuscles  takes  place  into  the  neurilemma,  an  exudation  partly  serous, 
partly  fibrinous,  and  minute  extravasations  occur  between  the  fasciculi, 
and  then  suppuration  and  softening  result.  Recovery  may  ensue  be- 
fore disintegration  of  the  nerve-elements  is  produced.  The  fibrinous 
exudation  undergoes  the  usual  changes — the  watery  part  is  absorbed, 
the  solid  matters  and  the  corpuscular  elements  become  fatty  and  are 
then  taken  up,  and  health  is  restored.  In  the  chronic  form  of  neuritis 
the  change  is  less  toward  pus-formation  and  softening,  and  more  to 
hyperj^lasia  of  the  connective  tissue.  The  nerve  forms  intimate  adhe- 
sions to  the  neighboring  connective  tissue,  the  medulla  undergoes  fatty 
degeneration,  and  the  nerve-fibers  and  axis-cylinder  atrophy.  These 
changes  may  occur  in  particular  j^arts  of  the  nerve,  giving  it  a  knobbed 
appearance,  whence  the  term  neuritis  nodosa.  It  is  important  to 
note  that  when  inflammation  occurs  in  a  nerve  it  may  extend  from  the 
point  first  diseased  upward  {neuritis  ascendens),  or  downward  [neuri- 
tis descendens).  By  the  extension  of  an  ascending  neuritis  the  spinal 
cord  may  be  ultimately  affected. 

Symptoms. — If  an  important  nerve  or  plexus  is  inflamed,  there  may 
be  some  fever  preceded  by  chilliness,  or  a  decided  chill,  headache,  and 
general  muscular  soreness  ;  but  the  most  pronounced  symptom  is  pain 
in  the  nerve,  not  only  at  the  point  inflamed,  but  spreading  thence  over 
the  peripheral  distribution.     The  pain  is  of  a  very  distressing  kind  ; 


NEURITIS.  (325 

it  is  a  burning,  tingling,  tearing,  and  intense  pain,  and  is 'increased  by 
motion  or  pressure.  There  is  a  high  degree  of  sensitiveness  in  the 
region  of  the  inflammation  ;  numbness  and  formication  are  mixed  with 
the  pain,  and  ultimately  tlie  parts  supplied  by  the  nerve  become  anaes- 
thetic, which  means  destruction  of  the  nerve,  or  pressure  sufficient  to 
prevent  the  transmission  of  impulses.  If  the  nerve  inflamed  be  motor 
in  function  as  well  as  sensory,  there  will  occur  spasmodic  contractions 
and  cramps  in  the  muscles  to  which  the  nerve  is  distributed  ;  then  will 
follow  paresis,  and  ultimately  paralysis,  if  the  nerve  is  compressed  or 
destroyed.  Besides  the  general  fever  accompanying  the  neuritis,  there 
is  a  local  elevation  of  temperature  in  all  the  region  of  distribution 
of  the  nerve.  In  the  chronic  form  there  do  not  occur  the  constitu- 
tional symptoms  which  are  present  in  the  acute  form,  but  pain  and 
other  symptoms  of  sensory  irritation,  and  cramps  and  other  symptoms 
of  motor  irritation,  do  appear.  Besides  the  effects  of  neuritis  within 
the  distribution  of  the  affected  nerve,  various  reflex  and  radiation  phe- 
nomena are  manifest.  Pain  is  felt  in  all  the  branches  of  the  same 
plexus,  and  cramp  in  the  muscles  innervated  from  the  same  source. 
Wasting  and  degeneration  of  the  muscles  and  anaesthesia  of  the  parts 
innervated  by  the  affected  nerve  are  results  of  the  neuritis.  Various 
trophic  disturbances  are  also  caused.  These  have  been  best  described 
by  Mitchell.*  Various  forms  of  cutaneous  eruptions  appear — herpes, 
eczema,  and  "  glossy  skin  ";  the  nails  become  clubbed,  the  hair  falls  out, 
and  the  joints  swell  and  change  in  structure.  The  affected  nerve  in  the 
stage  of  irritation  responds  more  readily  to  electric  currents  ;  if  the 
nerve  is  simply  compressed  the  muscles  may  respond  normally,  yet 
if  destroyed  there  will  be  no  reaction  to  faradic  stimulation,  but  to 
slow  galvanic. 

Course,  Duration,  and  Termination. — The  acute  form  is  necessarily 
of  short  duration.  Recovery  ensues,  permanent  disability  results,  or 
it  becomes  chronic.  Restoration  is  possible  only  before  disintegration 
of  the  nerve.  The  chronic  form  has  no  fixed  duration.  Recovery  is 
more  likely  to  ensue  when  there  has  occurred  a  simple  injury  or  exte- 
rior pressure,  which  may  be  removed,  than  when  an  idiopathic  or  rheu- 
matic inflammation  has  taken  place.  The  latter  are  apt  to  become 
very  protracted,  to  have  periods  of  remission  and  exacerbation,  thus 
continuing  for  years.  The  prognosis  will  be  largely  determined  by 
the  character  of  the  symptoms — pain  and  muscular  cramps,  indicating 
the  stage  of  irritation — anaesthesia  and  paralysis,  the  stage  of  injury 
to  the  nerve-trunk.  Very  important  in  this  connection  is  the  electrical 
diagnosis — for,  if  the  irritability  of  the  muscles  to  the  faradic  cun-ent 
is  preserved,  the  nei'ves  are  still  intact,  and  vice  versa.  As  neuritis 
manifests  a  strong  tendency  to  ascend,  in  the  coui'se  of  the  malady 

*  "Injuries  of  Nerves  and  their  Consequences,"  Philadelphia,  18'72. 
40 


626  DISEASES  OF  THE  NERVOUS  SYSTEM. 

secondary  degeneration  of  the  spinal  cord  may  ultimately  take 
place.* 

Diagnosis. — The  differentiation  of  neuritis  from  myalgia  is  effected 
by  reference  to  the  points  of  tenderness — to  the  symptoms  of  irrita- 
tion, succeeded  by  those  of  depression  of  a  nerve  ;  from  neuralgia,  by 
the  fever  in  the  acute  form,  by  the  changes  in  the  trophic  condition  of 
the  skin,  and  by  the  state  of  the  muscles  and  the  reactions  to  the  f  ara- 
dic  current. 

Treatment. — The  various  causes  of  the  disease  must  be  removed. 
Here  surgical  treatment  of  wounds  and  injuries  may  be  invaluable. 
In  acute  cases  of  plethoric  and  vigorous  subjects,  leeches  should  be 
applied  along  the  course  of  the  nerve.  A  full  dose  of  morphia  and 
quinia  should  at  once  be  given  (gr.  ss. — gr.  xv  for  an  adult),  and  the 
tincture  of  aconite-root  (two  drops  every  two  hours) ;  or  morphia  may 
be  given  subcutaneously  if  the  pain  is  severe.  In  the  chronic  cases, 
the  most  effective  remedies  are  galvanism  and  the  hypodermatic  injec- 
tion of  morphia.  The  positive  pole  is  placed  on  the  tender  spot  or 
spots,  and  the  negative  at  the  peripheral  expansion,  daily  application 
of  a  few  minutes'  duration  being  made.  A  succession  of  flying-blis- 
ters, or  the  electric  brush,  or  the  oleate  of  morphia,  may  be  used  local- 
ly, the  iodide  of  potassium,  colchicum,  etc.,  intei*nally,  in  the  more  ob- 
stinate cases. 

ATROPHY  OF  THE   NERVES. 

Pathogeny. — Atrophy  of  the  nerves  arises  from  various  causes: 
from  central  diseases,  of  which  examples  are  afforded  by  posterior 
spinal  sclerosis,  progressive  bulbar  paralysis,  infantile  paralysis,  etc.; 
from  peripheric  lesions,  as  injuries  by  wounds,  or  compression  of 
tumors,  etc. 

Symptoms. — The  disturbances  by  atrophy  are  part  of  the  morbid 
complexus  of  various  affections,  and  consist  in  depression  of  func- 
tion, wasting  of  the  muscles,  paralysis,  and,  as  regards  the  sensory 
nerves,  anaesthesia, 

NEURALGIA— NEURALGIA  OF  THE  FIFTH  NERVE. 

Definition. — Neuralgia  of  the  fifth  nerve  has  received  various  desig- 
nations— prosopalgia,  tic-douloureux,  FothergilVs  disease,  etc. 

Causes. — The  causes  of  tic-douloureux  may  be  comprehended  in 
three  groups — constitutional,  immediate,  and  remote.  Heredity  is  an 
important  factor,  since  this  disease  is  one  of  numerous  maladies  possi- 
ble to  the  neurotic  temperament  or  disposition.  It  is  not  unfrequently 
associated  with  epilepsy,  as  Trousseau  was  the  first  to  point  out.     It 

*  Vulpian,  "Archives  de  Physiologie,"  vol.  ii,  1869,  p.  221,  "Experiences  relatives  ^ 
la  pathogenie  des  atrophies  secondaires  de  la  moelle  ^pini^re." 


NEURALGIA.  627 

may  occur  at  any  age,  but  is  more  frequent  from  the  middle  period,  on, 
and  in  women  at  the  climacteric  period.  Anstie  *  insists  on  the  impor- 
tance of  the  degenerative  changes  of  age  as  causes  of  the  origin  and 
of  the  intractable  character  of  some  cases.  The  female  sex  seem  more 
susceptible  than  males.  Certain  dyscrasiee,  as  lead,  syphilis,  malaria, 
etc.,  are  undoubtedly  causative.  Anaemia,  amenorrhoea,  a  depressed 
state  of  the  bodily  functions,  the  exhaustion  induced  by  excesses  in 
venery,  gout,  and  rheumatism,  are  predisposing  causes.  Psychical  im- 
pressions, especially  if  dej^ressing,  are  held  by  Anstie  to  be  causative. 
Changes  in  the  structure  of  the  nerve,  tumors,  exostoses,  and  aneur- 
isms, caries  of  the  bones,  periostitis,  gummata,  etc.,  are  among  the 
immediate  causes.  Decayed  teeth,  indigestion,  worms,  constipation, 
menstrual  derangements,  etc.,  are  among  the  remote  causes. 

Pathological  Anatomy. — The  changes  of  neuritis  have  been  some- 
times observed  in  the  trunk  of  the  nerve  and  in  the  ganglion  of  Gasser. 
More  frequently  no  changes  have  been  noted.  The  nerve  is  more 
often  affected  by  exterior  pressure.  In  one  of  the  most  severe  cases 
ever  witnessed  by  the  author,  the  nerve  was  impinged  on  by  an  aneu- 
rism of  the  basilar  artery,  and  was  very  much  thickened  and  soft- 
ened. Probably  the  most  frequent  pathological  condition  is  the  pres- 
sure of  an  exostosis,  or  other  form  of  tumor,  on  the  trunk  of  the  nerve 
within  the  cranium. 

Symptoms. — The  usual  history  is  that  of  gradually  increasing  pain 
in  the  face  or  teeth.  At  first  the  attacks  are  regarded  as  merely  tooth- 
ache, and  tooth  after  tooth  is  extracted  in  the  vain  hope  of  finding  the 
painful  one.  It  may  be  months  before  the  pain  assumes  the  charac- 
teristic expression.  Then  distinct  paroxysms  occur,  than  which  nothing 
can  be  more  horrible.  A  sudden  pain  pierces  the  face,  the  muscles  of 
that  side  are  convulsed,  the  eye  is  injected,  and  the  tears  flow — the 
patient  starts  up  with  a  terrible  groan,  rubs  the  cheek  vigorously, 
^Tings  his  hands,  cries  out  in  the  extremity  of  his  agony,  rushes  about 
his  apartment,  and  it  may  be  suddenly  the  pain  ceases  and  the  parox- 
ysm is  over,  or  it  gradually  subsides.  At  first  these  attacks  may  be 
weeks,  even  months  apart,  but  after  a  time  they  get  more  numerous. 
In  the  interval  between  the  seizures  there  may  be  entire  freedom  from 
pain,  but  in  many  cases  there  is  nearly  constant  soreness,  or  aching, 
in  the  jaws  or  eyes.  When  the  pain  is  wholly  paroxysmal,  the  attacks 
are  more  frequent,  and,  in  the  interval  between  them,  the  patient 
experiences  a  tense  feeling  in  the  affected  region  as  if  the  slightest 
movement  on  his  part  would  excite  a  paroxysm.  When  this  sensation 
comes  on,  he  durst  not  move,  he  can  not  be  spoken  to,  every  muscle  is 
in  a  state  of  tension  and  immovable,  he  hardly  breathes,  he  looks 
straight  before  him  in  an  attitude  of  suspense  and  apprehension.     In 

*  "Neuralgia  and  its  Counterfeits,"  London,  1811,  p.  31. 


628  DISEASES   OF   THE   NERVOUS   SYSTEM. 

spite  of  the  dreadful  energy  of  the  self-control,  his  effort  often  fails, 
the  pain  comes  on  with  a  lightning-stroke,  his  teeth  set  hard,  the  face 
pales,  the  pupil  dilates  ;  then  he  abandons  himself  to  his  suffering,  he 
starts  up  with  a  groan,  and  repeats  the  rubbing,  the  wringing  of  hands, 
the  cries,  etc.  Ultimately  so  sensitive  become  the  peripheral  nerves, 
that  the  slightest  touch,  a  breath  of  air,  excites  the  paroxysm,  and  the 
attempt  to  take  food  produces  the  most  frightful  torments,  the  face  is 
thrown  into  spasms,  tears  run  down  the  cheeks,  and  the  patient  utters 
horrible  groans.  So  dreadful  is  the  aspect  of  this  suffering,  that  these 
unfortunates  must  needs  eat  alone.  When  there  is  constant  suffering, 
there  are  certain  places  in  which  the  pain  is  felt — at  the  points  of 
emergence  from  the  bony  foramina  of  the  different  divisions,  and 
where  certain  filaments  become  superficial.  The  frontal  and  supra- 
orbital, the  infra-orbital,  and  the  mental,  are  examples  of  the  first  class, 
and  tenderness  and  pain  are  developed  by  pressure  on  the  nerves  at 
these  foramina.  These  are  nearly  if  not  quite  constant ;  but  those  are 
less  so,  felt  at  the  points  where  the  nerves  become  superficial.  The 
pains  radiate  from  the  painful  points  in  both  directions,  but  chiefly 
toward  the  periphery,  and  from  the  center,  on  other  nerve-trunks — on 
the  pneumogastric,  on  the  occipital,  etc.  The  sensibility  of  the  part, 
innervated  by  the  affected  nerve,  is  altered;  there  may  be  merely  per- 
verted sensations,  tingling,  formication,  etc.,  or  anaesthesia  when  the 
case  is  old,  hypergesthesia  when  the  attacks  are  recent.  Photophobia, 
amblyopia,  bleisharospasm,  and  spasms  of  the  facial  muscles  occur  dur- 
ing the  paroxysms.  Various  vaso-motor  disturbances  ensue,  such  as 
herpetic  erujjtions  (zoster),  eczema,  falling  out  of  the  hair,  a  glossy 
state  of  the  skin,  ophthalmia,  in  old  cases,  and  in  the  recent  attacks, 
injected  conjunctiva,  lachrymation,  swollen  face,  thickened  skin,  inject- 
ed nasal  mucous  membrane,  etc.  When  paroxysms  are  brought  on  by 
eating,  and  when  sleep  is  prevented,  the  general  health  declines,  but 
otherwise  there  may  be  no  constitutional  symptoms.  Tic-doiiloureux 
may  occur  in  one  or  all  divisions  of  the  fifth  ;  more  frequently  it  is 
either  confined  or  is  most  violent  in  one  of  these  divisions.  When  the 
ophthalmic  division  is  affected,  pain  extends  into  the  forehead  and 
temples,  the  eyelid,  and  the  eye  itself.  The  principal  painful  spot  is 
at  the  supra-orbital  foramen  ;  there  is  considerable  hyperaemia  of  the 
conjunctiva,  photophobia,  and  spasm  of  the  orbiculus  palpebrarum. 
When  the  second  division  is  attacked,  the  pain  is  felt  in  the  superior 
maxilla,  in  the  teeth,  and  the  upper  lip.  The  principal  tender  point  is 
at  the  infra-orbital  foramen.  When  the  third  or  inferior  maxillary 
division  is  attacked,  the  pain  is  felt  in  the  lower  jaw,  and  in  the  teeth, 
and  the  most  certain  painful  point  is  the  mental  foramen. 

Course,  Duration,  and  Termination. — Tic-douloureux  may  be  sev- 
eral years  in  its  development,  attacks  of  pain  becoming  gradually 
more  severe,  better  defined,  and  paroxysmal.     It  is  therefore  a  chronic 


NEURALGIA.  g29 

disease.  That  form  dependent  on  malarial  infection  occurs  more 
abruptly,  has  distinct  periodicity,  and  terminates  promptly,  if  appro- 
priately treated,  or  assumes  some  other  form.  If  caused  by  an  aneu- 
rism, or  tumor,  or  exostosis,  the  course  is  slow  but  usually  uniform,  and 
the  pain  and  hyperaesthesia  are  excessive  ;  but  after  a  time  anaesthesia 
occurs  and  the  pain  declines.  In  the  purely  neuralgic  form  there  is 
no  regularity  in  the  paroxysms,  and  a  state  of  the  peripheral  nerves  is 
ultimately  reached  when  paroxysms  are  induced  by  the  slightest  move- 
ment. In  the  rheumatic  subject,  changes  of  temperature  and  baro- 
metric pressure  may  determine  attacks  which  can  be  predicted.  The 
simpler  forms  may  terminate  in  recovery,  but  those  cases  due  to 
exterior  pressure  on  the  trunk  of  the  nerve  within  the  cranium  are 
incurable.  Severe  and  protracted  cases  may  terminate  in  epileptic 
attacks,  or  induce  insanity,  or  lead  to  suicide. 

Diagnosis. — To  determine  the  cause  of  the  neuralgia  may  be  very 
difficult,  and  to  separate  the  cases  purely  neuralgic  from  those  due  to 
some  intra-cranial  growth  may  be  impossible  at  the  outset.  There  is 
no  difficulty  in  diagnosticating  the  seat  and  character  of  the  neuralgia, 
apart  from  the  lesion  producing  it.  An  intra-cranial  growth  affecting 
the  nerve  will  be  accompanied  by  other  sensory  and  motor  disturb- 
ances— by  strabismus,  double  vision,  vertigo,  incoordination,  paraly- 
sis, etc. 

Treatment. — In  cases  produced  by  some  form  of  infection,  syphi- 
litic, rheumatismal,  plumbic,  or  malarial,  treatment  must  necessarily 
be  directed  to  the  underlying  cause.  In  every  case  in  which  no  ex- 
planation is  possible  of  the  origin  of  the  disease,  it  is  good  practice  to 
prescribe  a  course  of  iodide  of  potassium.  For  the  relief  of  recent 
cases,  beginning  suddenly  and  with  violence,  full  doses  of  quinia  and 
morphia  (gr.  xv — gr.  xx  of  quinia  and  gr.  ss.  of  morphia)  are  to  be 
commended.  Duquesnel's  aconitine  in  solution,  internally,  in  from  yi-g- 
grain  to  -gL-  grain,  even  -^  grain,  very  cautiously,  has  been  successful  in 
some  cases  of  pure  neuralgia  of  the  fifth.  Fluid  extract  of  gelsemium 
has  had  a  curative  effect  in  some  cases,  and  a  palliative  effect  in  others. 
It  should  be  carried  to  the  point  of  inducing  ]Dtosis,  dilated  pupil,  and 
muscular  languor.  To  afford  relief,  there  is  no  remedy  comparable  to 
the  subcutaneous  use  of  morphia,  and  this  relief  may  be  permanent, 
but  is  not  frequently  so,  and  the  danger  of  inducing  a  morphia-habit 
is  very  great  in  a  disease  of  this  kind.  The  combination  of  morphia 
and  atropia  is  preferable  to  morphia  alone.  Atropia  hypodermatically 
has  effected  a  cure  in  some  cases.  These  remedies,  if  continued  for  a 
great  while,  lose  their  effect,  and  the  pain  which  they  at  first  relieved 
seems  to  be  caused  by  them  at  last.  Injections  in  the  vicinage  of  the 
diseased  nerve  have  been  used  with  success.  Water  has  been  so  used, 
and  has  afforded  some  relief.  Of  all  the  remedies  thus  far  proposed, 
none  have  been  so  successful  as  the  deep  injection  of  chloroform.    This 


630  DISEASES   OF   THE   NERVOUS   SYSTEM. 

method  is  adapted  to  those  cases  of  neuralgia  in  nerves  superficially 
placed,  as  the  supra-  and  infra-orbital  nerves,  because  the  chloroform 
must  be  deposited  about  the  nerve  or  in  its  neighborhood.  The  author 
has  published  some  cases  showing  the  extraordinary  relief,  lasting 
months,  and  permanent  cures  which  have  thus  resulted.  The  method 
consists  in  depositing  in  the  neighborhood  of  the  nerve  from  five  to 
ten  minims  of  pure  chloroform  by  means  of  the  hypodermatic  syringe. 
The  constant  galvanic  current,  stabile  and  descending,  always  affords 
great  relief  to  the  pain,  and  may  in  jDurely  neuralgic  cases  bring  about 
a  cure.  Daily  aj^plications  of  a  few  minutes  should  be  kept  up  for  a 
long  time  if  improvement  continues.  Means. to  promote  the  nutrition 
of  the  body  are  important,  for  in  neuralgia  the  vital  forces  are  usu- 
ally depressed.  If  anaemia  exists,  iron  is  necessary.  Arsenic  is  one 
of  the  most  powerful  of  the  so-called  nerve-tonics,  and  is  particularly 
serviceable  when  indigestion  exists.  The  phosphates  and  cod-liver  oil 
are  highly  useful  in  the  tic-douloureux  which  succeeds  to  lactation,  or 
in  all  conditions  of  bodily  depression.  Cold  and  warm  water-packs 
and  douches  are  to  be  commended,  and  resort  to  mountain  water  cures 
mav  be  advised  for  the  sake  of  change. 


OERVICO-OCCIPITAL,  CERVICO-BRACHIAL,  INTERCOSTAL,  AND 
LUMBO-ABDOMINAL  NEURALGIA. 

Pathogeiiy  and  Symptoms. — The  cervico-occipital  neuralgia  is  sit- 
uated in  the  region  innervated  by  the  four  upper  cervical  nerves. 
The  pain  is  felt  in  the  occipital  region  to  the  vertex  and  ear,  the  neck 
downward  to  the  clavicle,  and  upward  and  forward  to  the  cheek,  but 
chiefly  m  the  distribution  of  the  occipital  nerve.  The  pain  may  occur 
on  one  side  or  both,  but  usually  on  one,  is  deep,  heavy,  and  tensive,  or 
sharp  and  lancinating,  is  paroxysmal,  severe,  and  is  increased  by  every 
movement,  so  that  the  head  is  held  rigidly  in  one  position.  The  course 
of  the  occipital  nerve  is  tender.  Hypersesthesia  of  the  skin  and  cramps 
in  the  cervical  muscles  occur,  and  attacks  of  herpes  are  common. — 
Cervico-brachial  neuralgia  arises  under  the  same  conditions  as  the 
other  forms.  The  pain  is  very  severe,  of  a  boring,  burning,  heavy, 
and  tensive  chai-acter,  and  is  usually  very  severe  at  night.  The  pain 
is  accompanied  by  a  sense  of  numbness,  and  weakness  of  the  arm  and 
hand,  and  is  most  severe  in  the  shoulder  and  arm,  but  it  extends  down 
as  far  as  the  inferior  angle  of  the  scapula,  and  is  often  very  strong  in 
the  mamma  of  the  same  side.  The  cervical  plexus  is  very  tender,  and 
painful  points  are  felt  behind  the  acromion  process,  at  the  outer  part 
of  the  insertion  of  the  deltoid,  over  the  median  and  ulnar,  etc.  The 
spinal  apophyses,  corresponding  to  the  origin  of  the  nerves  implicated, 
are  tender.  Besides  the  pain  developed  by  pressure,  the  skin  of  the 
arm  at  various  points  is  hypersesthetic,  notwithstanding  the  numbness. 


NEURALGIA.  g31 

The  arm  feels  heavy  and  useless,  and  power  is  actually  impaired.  At 
the  outset,  the  arm  is  swollen  somewhat,  hot  and  rather  red,  but  in  an 
advanced  case  it  shrinks  from  disuse,  becomes  pale,  the  skin  glossy, 
dry,  and  harsh. — Intercostal  nexiralgia  is  produced  by  causes  besides 
those  of  the  other  forms  of  neuralgia.  Aneurisms  and  tumors  of  the 
chest  cause  very  violent  attacks  of  pain.  Diseases  of  the  vertebra 
and  ribs  have  the  same  effect.  The  pain  is  of  two  kinds — a  feeling  of 
soreness  with  fatigue,  and  an  acute  lancinating  pain.  As  in  the  other 
forms  of  neuralgia,  the  pain  is  paroxysmal,  remits  and  even  intermits. 
Pain  in  the  left  side,  usually  referred  to  the  sixth  or  seventh  inter- 
costal space,  is  very  common  in  women,  and  is  apparently  due  to  ova- 
rian and  uterine  irritation.  Intercostal  neuralgia  not  unfrequently 
takes  the  form  of  Icerpes  zoster  or  shingles.  The  author  has  seen  eight 
cases  in  which  the  herpes  seemed  to  be  due  to  arsenic,  and  others  have 
made  the  same  observation,  so  that  the  assumption,  that,  when  zoster 
accompanies  intercostal  neuralgia,  neuritis  is  the  cause  of  both  phe- 
nomena, seems  hardly  justified.  In  young  persons  there  is  not  much 
neuralgia  with  zoster,  and,  in  the  old,  the  neuralgia  precedes  and  suc- 
ceeds the  eruption.  In  most  cases  there  is  a  burning  pain  which  comes 
on  just  as  the  eruption  is  about  to  appear,  and  also  acute  lightning- 
pains  shooting  through  the  chest. — Lmnho-ahdominal  neuralgia  in- 
cludes the  ileo-hypogastric  nerve,  the  ileo-inguinal,  and  the  external 
spermatic  nerve  supplying  the  hypogastrium,  integument  of  the  hip, 
the  inner  face  of  the  thigh,  and  the  scrotum  or  labium,  but  neuralgia 
of  these  nerves  is  rather  uncommon. 


SCIATICA. 

Definition. — The  sciatic  plexus  is  made  up  of  the  fourth  and  fifth 
lumbar  and  the  first  two  pairs  of  sacral  nerves.  The  term  sciatica  is 
api^lied  to  a  neuralgic  affection  of  the  sciatic  nerve.  Sciatica  is,  next 
to  tic-douloureux,  the  most  important  of  the  neuralgic  affections. 

Pathogeny  and  Symptoms. — Constitutional  predisposition  and  he- 
redity have  less  to  do  with  sciatica  than  with  any  of  the  other  forms  of 
neuralgia.  The  disease  occurs  much  more  frequently  in  men  than  in 
women.  Direct  injury  to  the  nerve  in  certain  positions — sitting,  espe- 
cially if  the  form  of  the  seat  is  such  as  to  direct  the  weight  of  the 
body  on  the  nerve  ;  by  prolonged  walking  ;  by  constipation,  the 
bowel  being  distended  with  hardened  faeces — is  the  most  influential 
cause.  To  these  must  be  added  exposure  to  cold  and  dampness,  as, 
for  example,  prolonged  sitting  on  a  damp  stone,  fatiguing  work  in  the 
standing  posture  in  water,  etc,  .  These  causes  are  the  more  influential 
if  the  system  is  predisposed  by  rheumatism  and  other  cachexise  and  by 
the  neuropathic  constitution.  It  may  be  stated,  in  general  terms,  that 
sciatica  is  produced  by  the  same  causes,  constitutional,  immediate,  and 


032  DISEASES   OF   THE  NERVOUS   SYSTEM. 

remote,  that  otlier  forms  of  neuralgia  are,  but  that  it  is  much  more 
likely  to  be  developed  by  local  and  mechanical  than  by  systemic  and 
constitutional  causes.  The  only  pathological  alterations  proper  to 
sciatica  are  those  of  neuritis.  As  a  result  chiefly  of  disuse,  the  af- 
fected limb  wastes  more  or  less  in  severe  cases.  The  disease  develops 
slowly.  In  most  of  the  cases  observed  by  the  author,  an  attack  of 
lumbago  preceded  the  sciatica,  and  the  pain  gradually  became  fixed 
in  the  sciatic.  In  several  cases  (four)  the  pain  began  in  the  heel.  In 
other  cases  the  first  symptom  noted  was  a  feeling  of  pain  and  soreness 
in  the  hip.  A  feeling  of  stiffness,  numbness,  formication,  heaviness 
of  the  limb,  and  other  abnormal  sensations  have  been  noted.  In  what 
way  soever  the  disease  begins,  soon  severe  pains  occur  in  distinct 
l^aroxysms.  The  pains  are  lancinating,  tearing,  grinding,  and  they 
shoot  with  lightning-rapidity  along  the  direction  of  the  principal 
nerves.  Now  they  are  felt  with  greatest  intensity  in  the  hip  behind 
the  joint,  again  in  the  calf  of  the  leg,  now  in  the  ankle,  again  in  the  heel, 
or  the  pain  flies  from  one  to  another  of  these  parts,  or  shoots  through 
them  all  at  the  same  time.  The  paroxysms  last  a  variable  period  from 
an  hour  or  two  to  twenty-four  or  more  hours,  sometimes  for  several 
days,  there  being  brief  remissions  only.  The  pain  is  almost  always 
worse  at  night.  In  the  interval  between  the  paroxysms  the  limb  is 
heavy,  movements  excite  pain,  and  there  is  a  tensive,  throbbing  sen- 
sation which  threatens  severer  suffering.  Exercise  usually  increases 
the  pain,  and  unguarded  movements  may  bring  on  a  paroxysm.  The 
trunk  of  the  nerve  behind  the  trochanter  is  sensitive  to  pressure,  also 
in  the  popliteal  space  ;  there  are  tender  points  at  the  head  of  the 
fibula,  behind  the  inner  malleolus  and  also  behind  the  outer  malleolus, 
and  there  is  tenderness  of  the  lumbar  apophyses.  The  j^ain  often 
radiates  into  the  lumbar  nerves,  into  the  sciatic  of  the  opposite  side, 
and  into  the  scrotum  and  testes.  Hypersesthesia  and  cramps  occur  at 
first,  and  in  old  cases  diminished  sensibility,  lowered  temperature,  and 
wasting  are  observed.  The  appetite  is  impaired,  there  is  little  sleep 
in  bad  cases,  and  hence  the  bodily  forces  decline.  At  first  the  limb  is 
used  awkwardly,  the  patient  limps,  then  crutches  are  resorted  to,  and 
finally  the  bed  is  the  only  resource.  The  pitiable  state  to  which  a 
man  can  be  reduced  by  a  severe  sciatica  is  told  by  a  sufferer,  himself 
a  physician.  Dr.  Lawson  :  *  "  The  pain  persisted  for  more  than  six 
months  ;  it  first  reduced  me  to  the  employment  of  crutches,  and  then 
absolutely  prevented  locomotion  ;  the  limb  became  permanently  flexed 
and  terribly  wasted  ;  nearly  eveiy  remedy  in  the  Pharmacopceia,  and 
many  out  of  it,  were  tried  in  vain  ;  .  .  .  for  six  months  I  had  hardly 
known  what  sleep  was,  notwithstanding  the  administration  of  opiates 
three  or  four  times  a  day.     Appetite  was  utterly  lost  ;  physical  power 

*  "  Sciatica,  Lumbago,  and   Brachialgia,   etc.,"  by  Henry  Lawson,  M.  D.,  London, 
1812,  p.  1. 


NEURALGIA.  §33 

was  prostrate  ;  mind,  through  long  suffering,  was  enfeebled  to  that 
degree  that  I  look  back  upon  that  period  of  my  existence  with  aston- 
ishment and  horror."  Of  course,  not  all  cases  are  so  severe  as  this  of 
Dr.  Lawson,  but  in  every  mild  case  suffering  is  experienced,  the  sleep 
is  broken  more  or  less,  but  the  general  health  does  not  suffer  any  con- 
siderable deterioration. 

Course,  Duration,  and  Termination.  —  After  the  first  acute  symp- 
toms, when  the  case  begins  with  lumbago  and  a  feverish  state,  the  course 
is  chronic  and  like  the  usual  pattern.  When  the  symptoms  develop 
slowly,  the  disease  reaches  its  maximum  in  a  few  days,  or  a  week  or 
two.  If  the  treatment  be  appropriate,  a  termination  in  health  may 
take  place  in  two  or  three  weeks.  The  cases  often  continue  months 
and  years,  in  varying  condition,  now  improving,  then  getting  worse. 
In  the  author's  experience,  there  are  two  climatic  states  which  exercise 
'  an  unfavorable  influence — variable  cold  and  damp  weather  and  con- 
tinued high  temperature  ;  while  uniform  dry  cold  has  a  favorable  effect. 
Quite  irrespective  of  climatic  changes,  sciatica  has  a  strong  tendency 
to  relapses.  Some  cases  gradually  subside  without  any  properly  di- 
rected treatment,  and  get  well  in  a  year  or  two.  Many  do  not  recover 
entirely,  although  there  may  not  occur  any  acute  paroxysms  ;  the 
limb  continues  weak  and  a  halting  gait  persists,  because  of  im.per- 
fect  combination  of  the  muscles.  Cases  occurring  in  old  subjects, 
whose  symptoms  present  the  evidences  of  senile  degeneration,  may 
continue  during  life. 

Diagnosis. — Ordinarily  a  case  of  sciatica  does  not  offer  any  difficul- 
ties for  careful  consideration.  It  may  be  confounded  with  muscular 
rheumatism,  with  the  first  stage  of  hip-joint  disease,  and  with  hysteri- 
cal joint.  Muscular  rheumatism  differs  from  sciatica  in  the  lesser  se- 
verity of  the  pain,  in  the  absence  of  distinct  paroxysms,  and  in  the 
diffusion  of  the  symptoms,  the  distress  in  the  one  being  distributed 
over  the  principal  muscles,  in  the  other  confined  to  the  nerve-trunks 
and  to  certain  painful  points.  In  incipient  joint-disease  there  may  be 
much  sciatica,  so  that  the  distinction  must  rest  on  the  changes  in  the 
shape  of  the  hip,  in  the  gluteal  fold,  and  in  the  position  of  the  foot, 
which,  with  the  history,  ought  to  indicate  the  existence  of  hip-joint 
disease.  The  hysterical  joint  is  differentiated  by  the  absence  of  any 
evidence  of  suffering,  by  great  tenderness  in  the  skin,  and  yet,  when 
the  attention  is  withdrawn,  by  entire  lack  of  tenderness  in  the  nerve- 
trunk  or  in  tender  points,  and  by  the  evidences  of  hysteria  present. 

Treatment. — Existing  causes  should  be  removed.  '  If  the  attack 
depends  on  impaction  at  the  flexure  or  caecum,  active  purgatives  should 
be  prescribed.  A  particular  chair  or  habit  of  sitting  may  be  respon- 
sible, and  should  be  changed.  If  the  attack  begin  by  lumbago,  warm 
baths,  Russian  or  Turkish,  may  soon  effect  a  cure.  Dr.  Lawson, 
whose  shocking  experience  has  been  referred  to,  after  six  months  of 


634:  DISEASES   OF   THE   NERVOUS   SYSTEM. 

unavailing  treatment,  was  at  once  relieved  and  speedily  cured  by  the 
hypodermatic  injection  of  morphia.  His  little  work,  written  to  advo- 
cate this  treatment,  contains  numerous  cases  illustrating  its  utility. 
Morphia  (gr.  ^  to  gr.  i)  and  atropia  (gr.  yfg-  to  gr.  ^g-  to  gr.  -^)  are 
more  effective  in  combination  than  morphia  alone.  The  injection  is 
somewhat  more  effective  when  inserted  in  the  neighborhood  of  the 
affected  nerve.  There  can  be  no  doubt  that  this  treatment  is  sufficient 
in  itself  in  many  cases,  but  it  can  be  aided  by  other  measures,  local  and 
systemic.  The  author  has  witnessed  remarkable  cures  of  chronic  cases 
by  the  deep  injection  of  chloroform.  This  practice  consists  in  the 
injection  of  five  to  ten  minims  of  chloroform,  thrown  deeply  in  the 
neighborhood  of  the  nerve  near  to  the  point  of  its  emergence  from  the 
pelvis.  The  injection  should  alsa  be  practiced  at  those  points  where 
the  pain  has  been  severe.  But  few  injections  are  necessary.  Ether 
may  be  used  also,  but  it  is  more  irritating  and  less  effective.  The 
author  has  cured  many  cases  by  stabile  applications  of  galvanism 
alone.  A  large  sponge  electrode  should  be  applied  over  the  nerve 
near  the  point  of  exit  from  the  pelvis,  and  the  other  electrode  below. 
Strong  currents  are  more  effective  and,  indeed,  indispensable  for  cura- 
tive results.  Successive  portions  of  the  nerve  should  be  included  in 
the  circuit,  by  applying  the  anode  over  the  painful  points  and  the 
cathode  below,  according  to  the  method  of  Remak.*  Eulenberg,f 
Erb,J  and  Althaus,  are  fully  agreed  as  to  the  success  of  the  galvanic 
current  in  sciatica.  Hammond  has  revived  the  method  of  Magendie, 
and  now  cures  sciatica  by  inserting  an  acupuncture  needle,  insulated 
to  near  its  end,  and  passing  through  it  a  current  from  a  few  cells. 
Firing  is  often  very  successful.  The  hammer,  dipped  in  boiling  water, 
is  applied  to  produce  redness  and  slight  vesication,  or  considerable 
burning,  according  to  the  duration  of  the  case.  Great  relief  and  even 
curative  effects  have  followed  the  application  of  blisters,  the  raw  sur- 
face dressed  with  powdered  morphia.  Flying-blisters  are  beneficial. 
The  warm  pack  and  the  rubbing  pack  are  of  great  service  in  obstinate 
cases.  The  pack  may  be  worn  all  night.  In  the  chronic  cases  of  sup- 
posed rheumatic  origin,  iodide  of  potassium  guaiacum  and  turpentine 
are  said  to  be  useful,  but  the  author  has  not  seen  any  good  results 
from  them.  The  other  forms  of  neuralgia  referred  to  above  require 
the  same  treatment.  Any  local  injury,  constitutional  condition,  or 
cachexise,  must  be  removed.  The  most  successful  remedies  are  the 
hypodermatic  injection  of  morphia  and  the  constant  current,  the  cura- 
tive influence  of  which  few  cases  resist. 

*  "  Galvanotherapie,  traduit  de  rAUemand  par  le  Dr.  Morpain,"  Paris,  1860,  p.  374. 
•f-  "  Lehrbuch  der  fimctionellen  Nervenkrankheiten,"  op.  cit.,  p.  168. 
^  Ziemssen's  "  Cyclopajdia,"  vol.  xi. 


HISTRIONIC   SPASM.  635 


SPASM    OF    THE    FACIAL   MUSCLES    SUPPLIED   BY    THE    SEV- 
ENTH  NERVE— CONVULSIVE   TIC— HISTRIONIC    SPASM. 

Definition. — The  seventh  nerve  is  distributed  to  the  muscles  of  ex- 
pression. The  attacks  of  spasm  may  occur  in  all  or  a  part  of  these 
muscles.  Convulsive  tic  or  mimetic  sjKism  is  the  term  applied  to  the 
former  ;  hlepharospasm  is  the  name  given  to  spasm  of  the  eyelids. 

Pathogeny  and  Symptoms. — Various  causes  are  assigned  for  the 
production  of  mimetic  or  histrionic  spasm.  The  constant  activity  and 
variety  of  movement  in  expressing  the  various  emotions  render  these 
muscles  rather  apt  to  take  on  abnormal  movements.  This  is  seen  in 
tricks  of  expression  imitated  from  others,  and  also  inherited,  but  the  di- 
rect transmission  of  histrionic  spasm  is  not  common.  Men  are  more  apt 
to  suffer  from  this  malady  than  women.  It  may  occur  as  a  secondary 
symptom  in  such  convulsive  disorders  as  chorea,  epilepsy,  etc.  It  may 
be  developed  from  purely  psychical  states,  as  anger  or  fear,  but  then 
a  predisposition  must  exist.  It  is  more  apt  to  arise  from  direct  or 
reflex  irritation  of  the  facial  nerve.  Tumors,  caries  of  the  bones,  dis- 
eased teeth,  periostitis,  and  remote  irritation,  as  intestinal  worms,  have 
set  up  the  spasms.  The  disease  begins  in  a  small  group  of  muscles, 
and  then  extends  to  all  the  muscles,  on  one  side  usually,  although  both 
sides  may  be  affected.  It  consists  in  a  succession  of  clonic  spasms, 
producing  extraordinary  grimaces  and  contortions.  If  one  side,  it  is 
all  the  more  striking  by  comparison  with  the  unmoved  state  of  the  un- 
affected side.  The  spasms  occur  in  paroxysms,  lasting  a  few  seconds 
or  a  few  minutes.  They  begin  in  one  group  of  muscles  by  a  few 
twitches,  and  then  clonic  spasms  follow  in  all  the  others.  It  is  a  rule, 
however,  for  the  attack  to  be  more  decided  in  some  one  muscular  group, 
as  in  the  orbicularis  palpebrarum  and  corrugator  supercilii,  and  leva- 
tor labii  superioris  et  alseque  nasi  and  levator  anguli  oris.  The  num- 
ber of  the  attacks  varies  greatly,  usually  several  occurring  every  hour, 
and  they  may  persist  during  the  night,  but  this  is  not  usual.  They 
are  excited  by  attention  to  them,  by  talking,  by  emotion,  and  by 
increased  irritation  of  the  nerve-trunk.  They  do  not  interfere  with 
the  normal  use  of  the' muscles  at  other  times.  Extension  of  the  spasm 
may  take  place  to  the  muscles  of  the  tongue  and  to  those  of  mastica- 
tion, and  in  severe  paroxysms  the  muscles  of  the  neck  and  shoulders 
may  participate.  The  electro-contractility  of  the  m.uscles  remains  un- 
affected. Blepliarospas'm  is  the  form  of  the  disease  attacking  the  eye- 
lid. This  consists  of  paroxysmal  attacks  of  sudden  closure  of  the  lids, 
with  spasms  of  the  annexed  muscles,  producing  extraordinary  grimaces 
of  the  affected  eye.  The  attacks  may  occur  suddenly  without  any  ap- 
parent cause,  or  be  induced  by  straining  or  irritation  of  the  eyes,  by 
opening  or  closing  the  lids.  The  conjunctiva  is  injected,  there  is  a 
profuse  secretion  of  tears,  and  an  extreme  degree  of  photophobia  may 


636  DISEASES   OF  THE  NERVOUS  SYSTEM. 

exist.  These  changes  may  be  the  result  of  blepharospasm,  but,  in  a 
great  majority  of  cases,  diseases  of  the  eye,  as  scrofulous  conjunctivitis, 
corneitis,  wounds,  by  irritating  the  sensory  fibers  of  the  fifth,  excite 
the  spasms  by  a  reflex  mechanism.  In  this  disease  certain  so-called 
pressure-points  exist,  pressure  on  which  will  suddenly  arrest  the  par- 
oxysms. These  have  no  fixed  position,  as  the  painful  points  in  neu- 
ralgia, and  can  not  be  indicated  beforehand  in  any  case,  but  must  be 
searched  for.  They  are  sometimes  found  at  the  supra-orbital  foramen, 
and  on  various  branches  of  the  fifth  nerve  in  the  face,  the  gums,  the 
malar  bone,  and  the  mastoid  process,  and  if  not  detected  in  these  situ- 
ations may  be  discovered  in  the  brachial  plexus,  the  spinous  processes, 
or  the  sympathetic.  Pressure  on  these  points  exerts  an  inhibitory  influ- 
ence on  the  spasms,  which  may  be  suspended  for  some  time.  On  the 
other  hand,  the  influence  of  the  pressure-points  may  continue  only 
during  the  pressure  (Erb). 

Treatment. — The  removal  of  any  cause  of  irritation,  intrinsic  or 
extrinsic,  is  necessary.  As  blepharospasm  is  so  often  due  to  strumous 
diseases  of  the  eye,  these  must  be  removed  before  any  influence  can 
be  exerted  on  the  spasm.  Remarkable  results  have  been  obtained 
from  the  free  use  of  siiccus  conii  in  this  malady  ;  in  recent  cases,  the 
subcutaneous  use  of  morphia,  and  morphia  and  atropia.  The  hypo- 
dermatic injection  of  Fowler's  solution  has  succeeded  remarkably  in 
some  cases  of  tic.  From  two  to  five  drops  can  be  injected  daily  about 
the  pes  anserinus.  The  constant  current  (stabile)  applied  to  the  pres- 
sui'e-points,  the  positive  pole  on  the  point,  the  negative  held  on  some 
part  of  the  periphery,  has  been  successful  in  some  cases.  The  sympa- 
thetic, the  mastoid  process,  the  vertebrae,  etc.,  are  also  possible  pressure- 
points  to  which  the  current  should  be  applied.  Remarkable  results 
have  followed  the  section  of  the  supra-orbital  nerve  in  a  few  cases. 


SPASM    OP    THE    MUSCLES     SUPPLIED    BY    THE     SPINAL    AC- 
CESSORY—TORTICOLLIS. 

Pathogeny  and  Symptoms. — The  trapezius  and  the  sterno-cleido- 
mastoid  are  the  muscles  affected  either  separately  or  together,  and  the 
attack  may  be  unilateral  or  bilateral.  In  unilateral  spasm  of  the 
sterno-cleido-mastoid,  the  head  is  rotated  a  little,  the  chin  elevated 
and  turned  to  the  other  side,  and  the  occiput  is  brought  forward  and 
downward  in  the  direction  of  the  clavicle.  If  the  trapezius  is  alone 
affected,  the  head  is  drawn  down  and  backward,  and  the  shoulder  up- 
ward and  inward  toward  the  spine.  When  both  muscles  are  affected, 
there  is  a  combination  of  the  movements,  and  they  may  alternate.  In 
bilateral  spasms  of  the  spinal  accessory,  the  head  is  drawn  from  one 
side  to  the  other,  and  the  chin  correspondingly  turned  in  the  opposite 
direction.     If  the  sterno-mastoids  are  alone  affected,  there  occur  sym- 


TORTICOLLIS.  637 

metrical  nodding  movements.  The  attacks  of  spasm  are  paroxysmal, 
and  are  of  variable  duration,  lasting  from  a  few  minutes  to  a  number 
of  hours.  They  may  be  very  severe,  tossing  the  head  from  side  to 
side  in  a  terrible  manner,  and  may  be  almost  continuous,  involving 
also  the  muscles  of  the  face,  of  mastication,  and  of  the  shoulder. 
Sleep  usually  arrests  the  movements,  and  is  quiet  and  undisturbed, 
although  it  may  be  delayed,  and  sometimes  entirely  prevented.  The 
paroxysms  are  excited  by  any  kind  of  irritation,  as  of  talking,  mental 
excitement,  anger,  and  are  increased  by  the  attention  given  to  the 
spasms  by  others.  As  a  necessary  result,  the  wild,  disorderly,  and 
very  strong  movements  exhaust  the  muscles.  In  the  course  of  the 
paroxysms,  speech  and  mastication  are  prevented.  The  unpleasant 
condition  of  these  patients  and  the  nervous  disorder  probably  associ- 
ated with  it  slowly  bring  about  a  mental  change.  These  patients  are 
depressed  and  gloomy,  sometimes  suicidal,  and,  in  the  further  progress 
of  the  case,  epilepsy,  paralysis,  or  insanity  may  be  a  result. 
'  Treatment. — There  is  little  to  encourage  therapeutic  effort,  and 
partly  because  the  origin  remains  obscure.  Those  cases  brought  on 
by  exposure  of  the  neck  to  draughts  of  cold  and  damj)  air  are  the 
most  remediable.  If  there  be  a  source  of  reflex  irritation  which  can 
be  removed,  as  worms,  indigestion,  or  uterine  disease,  the  muscular 
disorder  may  be  readily  cured  if  treated  in  time.  When  there  ai'e 
intra-cranial  lesions,  or  if  the  case  be  chronic,  and  occurring  in  the 
neuropathic  constitution,  the  treatment  is  in  vain.  The  best  results 
are  obtained  from  the  constant  galvanic  currents,  stabile  applications, 
and  by  applications  to  the  sympathetic  and  to  the  spine.  Next  in 
efficiency  is  the  hypodermatic  injection  of  morphia,  if  possible,  into 
the  muscles  affected.  The  injections  of  arsenic  should  be  tried  in 
doubtful  cases.  The  warm  pack  should  be  steadily  worn  at  night, 
and  douches  to  the  cervical  spine  applied  warm  or  cold,  according 
to  the  results.  The  actual  cautery  has  been  used  with  success  in  a 
few  cases.  In  that  form  of  torticollis  in  which  the  muscles  assume 
a  condition  of  tonic  spasm,  they  are  fixed  in  a  permanent  position 
by  contraction.  If  the  steruo-cleido-mastoid  is  affected,  it  stands  out 
prominently  and  is  enlarged  and  rigid,  and  the  head  assumes  a  charac- 
teristic attitude,  the  chin  turned  away,  and  the  occiput  brought  down 
and  forward  toward  the  clavicle.  When  the  trapezius  is  alone  affected, 
the  head  and  shoulder  are  approximated,  and  the  anterior  border  of  the 
muscle  forms  a  prominent,  rigid  swelling.  The  affected  muscles  have 
a  sore,  tired  feeling,  and  are  tender  to  the  touch  when  the  affection  is 
recent.  The  antagonistic  muscles  after  a  time  undergo  atrophy,  and 
hence  the  overacting  muscles  are  aided  in  maintaining  the  fixed  posi- 
tion of  the  head.  In  young  spines  a  permanent  curvature  of  the  cer- 
vical part  takes  place,  and  the  features  accommodate  themselves  to  the 
changed  position  of  the  head  in  a  most  remarkable  way.     The  bones 


638  DISEASES   OF  THE   NERVOUS   SYSTEM. 

of  the  face  undergo  a  slow  transformation  to  permit  the  features  to 
assume  the  new  relations.  In  this  disease  it  is  highly  important  to 
undertake  the  treatment  before  the  deformity  becomes  permanent. 
Electricity  is  entitled  to  the  first  place  as  a  remedy.  There  are  two 
methods  of  application  to  be  employed.  Stabile  applications  are  to  be 
made  to  the  muscles  in  a  state  of  spasm,  and  faradic  currents  to  the 
antagonistic  muscles.  Warm  packs,  massage,  and  gymnastic  training 
are  useful.     Surgical  treatment  is  necessary  in  chronic  cases. 


SPASM   OF   THE  DIAPHRAGM— SINGULTUS— HICCOUGH. 

Pathogeny  and  Symptoms. — This  malady  consists  in  a  recurring 
spasm  of  the  diaphragm ;  there  is  first  a  full  expiration,  then  a  sudden 
inspiration,  accompanied  by  a  high  tension-sound,  caused  by  a  spas- 
modic closure  of  the  glottis.  It  is  often  present  without  having  any 
significance.  It  is  a  symptom  of  certain  kinds  of  indigestion,  and  is 
present  only  during  the  stage  of  digestion.  Distention  of  the  stomach 
may  cause  it.  Hepatic  diseases — peritonitis,  chronic  ileocolitis — are 
maladies  during  the  course  of  which  hiccough  may  come  on,  especially 
in  the  collapse  which  ushers  in  death.  It  is  a  symptom  of  irritation 
of  the  respiratory  center,  and  of  various  diseases  of  the  central  nervous 
system,  and  is  one  of  the  manifold  forms  in  which  hysteria  manifests 
itself.  The  worst  case  ever  seen  by  the  author  occurred  after  a  severe 
attack  of  hepatic  colic.  When  the  paroxysms  are  protracted  and  the 
hiccough  is  frequent,  very  considerable  suffering  is  the  result.  The 
hiccough  may  occur  as  often  as  one  hundred  to  the  minute,  and  the 
paroxysms  may  continue  for  some  hours  or  days,  returning  from  time 
to  time  during  several  years.  The  attacks  may  have  a  certain  rhythm, 
three,  six,  or  other  numbers  occurring  in  succession,  then  an  intermis- 
sion. When  a  severe  paroxysm  comes  on,  severe  pain  is  felt  in  the 
epigastrium,  the  respiration  is  disturbed,  eating  is  difficult,  and  sleep 
may  be  prevented. 

Treatment. — A  strong  mental  impression  or  a  draught  of  very  cold 
or  very  hot  liquid  will  sometimes  succeed  in  arresting  hiccough.  Elec- 
tricity is  usually  very  successful.  In  the  severe  case  just  mentioned 
the  author  arrested  the  spasm  instantly,  after  all  kinds  of  remedies,  in- 
cluding galvanization  of  the  phrenic,  had  been  tried  in  vain,  by  send- 
ing a  strong  faradic  current  through  the  diaphragm  just  as  the  spasm 
was  about  to  occur.  The  inhalation  of  ether,  of  nitrite  of  arayl,  and 
the  injection  of  pilocarpine,  have  all  promptly  succeeded. 

PARALYSES  OF  THE  OCULAR  MUSCLES. 

Pathogeny  and  Symptoms. — Paralysis  of  the  muscles  of  the  eye  is 
a  symptom  rather  than  a  disease.     Rarely  does  a  case  happen  in  which 


PARALYSES   OF   THE   OCULAR   MUSCLES.  639 

the  paralysis  is  due  to  rheumatic  inflammation.  More  frequently 
penetrating  wounds,  contusions,  and  fractures,  are  causes.  The  sec- 
ondary paralyses  are  more  numerous  than  the  primary.  Diseases  of 
the  brain,  such  as  cerebral  haemorrhage,  tumors  so  situated  as  to  com- 
press the  nerve-trunks,  affections  of  the  spinal  cord,  as  posterior  spinal 
sclerosis,  and  the  paralysis  following  diphtheria,  are  the  most  influen- 
tial causes.  When  the  muscles  are  weak,  the  movements  of  the  ocular 
globe  are  affected,  a  fact  which  may  be  made  apparent  by  comparing 
the  sound  with  the  impaired  eye  ;  the  limit  of  rotation  will  be  seen  to 
be  less,  and  the  obvious  result  is  strabismus.  Before  this  is  apparent 
by  ordinary  inspection,  the  patient  complains  of  diplopia  (double 
vision).  Or  there  is  confused  double  vision,  the  patient  being  affected 
only  in  certain  parts  of  the  visual  field.  The  secondary  deviation  of 
the  sound  eye  is  a  very  characteristic  sign.  "  The  field  of  vision  is 
disj)laced  in  the  direction  of  the  action  of  the  paralyzed  muscle,"  which 
leads  to  erroneous  perception  of  the  position  of  objects.  The  disturb- 
ances of  vision  caused  in  this  way  induce  giddiness  and  more  or  less 
pain.  Covering  the  eye  prevents,  of  course,  the  formation  of  a  double 
image,  and  thus  affords  some  relief.  When  the  motor  ocidi  is  para- 
lyzed, there  is  ptosis  (dropping  of  the  eyelid),  and  the  movements  of 
the  eye  downward,  inward,  and  upward,  are  lost.  The  pupil  is  dilated 
and  motionless  because  of  the  unopposed  action  of  the  sympathetic,  and 
the  power  of  accommodation  to  near  and  distant  objects  is  very  much 
lessened.  As  the  external  rectus  and  superior  oblique  continue  in 
action,  the  eye  becomes  fixed  in  the  direction  downward  and  outward. 
The  eye  is  usually  prominent  because  of  the  paralysis  of  the  straight 
muscles,  allowing  the  globe  to  glide  forward.  There  is  double  vision, 
and,  as  the  field  of  vision  is  falsely  projected  in  every  direction,  there 
is  great  disturbance  of  visual  perceptions,  and  consequently  giddi- 
ness, so  that  the  eye  is  ordinarily  kept  closed.  In  paralysis  of  the  ab- 
ducens,  the  external  rectus  muscle  is  unable  to  move  the  eye  outward, 
and  there  is  consequently  convergent  strabismus. 

Course,  Duration,  and  Termination. — There  are  very  great  varia- 
tions in  the  course  of  these  affections,  as  they  are  dependent  on  various 
causes.  The  rheumatic  affections  may  be  regarded  as  curable  with 
comparative  facility,  but  those  examples  due  to  intra-cranial  lesions, 
unless  syphilitic,  pursue  the  course  of  the  original  disease,  and  are 
incurable.  The  accompanying  symptoms  are  of  great  importance 
in  coming  to  a  conclusion  as  to  the  seat  and  character  of  the  local 
disease. 

Treatment. — If  syphilitic,  rheumatismal,  or  plumbic  lesions  be  the 
cause,  the  treatment  appropriate  to  these  diatheses  should  be  carried 
out.  In  the  absence  of  any  specific  cause,  a  course  of  the  iodide  of 
potassium  should  always  be  undertaken.  The  most  important  remedy, 
and  one  from  which  most  striking  results  are  obtained,  is  electricity. 


540  DISEASES   OF   THE   NERVOUS   SYSTEM. 

Labile  applications  of  galvanism  are  the  most  effective — the  anode 
placed  on  the  mastoid,  and  the  cathode  passed  over  the  eyelids.  The 
current  must  be  strong  enough  merely  to  cause  movements  of  the  facial 
muscles,  and  the  length  of  the  sitting  should  be  about  three  minutes. 
The  sympathetic  may  also  be  galvanized  in  the  usual  way.  The  f ara- 
dic  current,  which  is  greatly  more  painful,  may  be  used  instead  in  some 
cases — one  pole  on  the  temple,  and  the  other,  covered  with  soft  leather, 
to  the  conjunctiva  at  the  situation  of  the  paralyzed  muscle,  if  possible. 


PARALYSIS    OF    THE    FACIAL    NERVE— FACIAL    PARALYSIS. 

Causes. — Exposure  to  a  current  of  cold  air,  directed  against  the 
main  divisions  of  the  nerve  in  front  of  the  ear  (pes  anserinus),  is  the 
most  usual  cause,  and  of  the  simplest  variety  of  the  disease.  Such 
exposure  acts  by  exciting  some  inflammation  of  the  neurilemma  ;  in 
the  Fallopian  canal  serous  and  occasionally  plastic  exudation  occurs 
and  compresses  the  nerve.  Injuries  to  the  nerve  in  front  of  the  ear 
are  very  common,  but  the  most  usual  cause,  next  to  cold — the  so- 
called  rheumatic  inflammation — is  disease  of  the  middle  ear.  Syphi- 
litic deposits,  gummata,  etc.,  may  invade  the  nerve  before  its  entrance 
into  the  canal,  and  also  various  diseases  of  the  basal  ganglia,  tumors, 
exostoses,  etc.  Again,  facial  paralysis  occurs  with  hemiplegia,  or  it 
may  be  crossed  in  disease  of  the  pons. 

Symptoms. — No  disease  is  more  distinctive  than  facial  paralysis. 
The  affected  side  is  perfectly  blank,  motionless,  without  wrinkles,  the 
corner  of  the  mouth  depressed,  the  eye  wide  open,  and  the  tip  of  the 
nose  and  the  whole  side  drawn  over  to  the  healthy  side,  which  is  more 
strongly  marked  by  furrows  and  wrinkles  than  before.  This  condition 
of  the  muscles  may  occur  suddenly  :  the  patient,  on  looking  in  the  mir- 
ror in  the  morning,  is  astonished  and  alarmed  at  the  change  ;  or,  feel- 
ing an  odd  sensation  in  the  lips  and  tongue,  he  attempts  to  expectorate, 
and  finds  he  can  not  use  his  lips  properly.  There  may  be  premonitory 
symptoms  for  some  hours,  even  a  day  or  two  before  the  attack,  con- 
sisting of  numbness  and  tingling  of  the  lips,  a  strange  taste,  acid  or 
metallic,  pains  in  the  face  or  ear-ache,  noises  in  the  ear,  or  there  may 
be  present  an  otorrhoea.  Again — and  this  is  especially  true  of  disease 
of  the  middle  ear — the  paralysis  may  develop  slowly,  one  group  of 
muscles,  then  others,  becoming  paralyzed,  and,  when  complete,  all  of 
the  muscles  innervated  by  the  seventh  nerve  are  affected.  When  this 
occurs,  no  movements  can  be  effected  by  these  muscles.  The  eye 
remains  open  ;  the  conjunctiva  inflames  in  consequence  of  the  particles 
of  dirt  which  alight  and  adhere  ;  there  is  a  profuse  flow  of  tears  ;  in 
attempts  to  close  the  eyes,  the  upper  lid  falls  and  the  globe  rotates 
upward  and  inward,  but  the  lids  do  not  approximate,  and  hence  the 
eye  remains  open,  and  in  time  the  lower  lid  becomes  somewhat  everted  ; 


FACIAL  PARALYSIS.  641 

the  forehead  can  not  be  corrugated.  The  coi-ner  of  the  mouth  can  not 
be  elevated,  the  lips  can  not  be  pursed  up  in  the  attempts  to  whistle, 
and  in  smiling  the  affected  side  remains  motionless,  while  the  sound  is 
acting  strongly.  The  saliva  escapes  from  the  mouth,  and  the  labials 
can  not  be  pronounced,  whence  the  speech  is  rather  mumbling  and  in- 
distinct. Mastication  is  difficult  and  the  alimentary  bolus  accumulates 
in  the  cheek  of  the  paralyzed  side.  Not  unfrequently  the  sense  of 
taste  on  one  side  of  the  tongue  is  abolished,  and  the  secretion  of  saliva 
lessens.  When  this  is  the  case,  the  chorda  tympani,  which  Schiff  has 
shown  is  the  nerve  of  taste  to  the  anterior  half  of  the  tongue,  is  af- 
fected, and  it  therefore  follows  that  the  seventh  is  damaged  at  the 
point  of  origin  of  this  nerve.  The  uvula  is  often  affected  also,  and 
hangs  paralyzed,  deviating  toward  either  side.  When  this  organ  is 
affected,  the  speech  is  nasal,  swallowing  is  difficult,  and  liquids  come 
through  the  nose.  This  paralysis  of  the  uvula  is  necessarily  due  to 
implication  of  the  superficial  petrosal  nerve.  The  ear  is  usually  unaf- 
fected, although  noises  are  heard.  The  sensibility  of  the  paralyzed 
side  is  normal.  The  reflex  movements  are  entirely  abolished  when 
the  disease  occupies  any  part  of  the  trunk  of  the  seventh  from  its  ori- 
gin outward.  In  case  of  hemiplegia  the  reflex  excitability  is  pre- 
served. In  the  mildest  cases  the  electro-sensibility  and  contractility 
are  perfectly  normal.  In  the  more  severe  cases  the  muscles  may  not 
respond  to  a  faradic  current,  yet  do  respond  to  a  slowly  interrupted 
galvanic  current ;  but  the  nerves  themselves  lose  their  excitability  to 
both  cuiTents  during  the  period  of  regeneration.  The  muscles  may 
ultimately  lose  their  galvanic  excitability  when  they  have  undergone 
advanced  changes.    When  this  is  the  case,  the  prognosis  is  unfavorable. 

Course,  Duration,  and  Termination. — When  the  external  branches 
of  the  seventh  only  are  affected,  and  by  such  a  simple  cause  as  ex- 
posure to  a  current  of  cold  air,  the  duration  will  be  short,  and  recov- 
ery effected  in  two  or  three  weeks.  The  more  severe  cases  may 
require  twice  the  time  of  the  former.  In  those  cases  characterized  by 
loss  of  faradic  and  retention  of  galvanic  excitability  of  the  muscles, 
the  duration  will  be  several  months,  even  a  year  may  elapse  before 
restoration.  In  these  cases,  after  a  time,  the  muscles  become  rigid  and 
retract  somewhat,  and  they  may  be  affected  by  spasmodic  contractions 
resembling  tic.  In  traumatic  paralysis,  the  amount  of  recovery  de- 
pends on  the  extent  of  injury  to  the  nerve.  Usually  restoration  in  the 
most  favorable  cases  is  incomplete.  The  same  observations  may  be 
made  of  paralysis  from  pressure  of  the  nerve,  the  degree  and  curabil- 
ity of  injury  determining  the  result. 

Diagnosis. — The  diagnosis  is  reached  by  mere  inspection,  but  to  as- 
certain the  seat  of  the  injury  to  the  nerve  is  more  difficult.  Whether 
peripheral  or  central  is  arrived  at  by  attention  to  the  following 
points  :  in  peripheral  paralysis,  the  eye  is  wide  open  even  in  sleejo, 
41 


642  DISEASES   OF   THE   NERVOUS  SYSTEM. 

and  reflex  movements  of  the  lids  are  abolished,  which  is  not  the  case 
in  cerebral  paralysis  ;  the  abolition  of  faradic  and  the  retention  of 
galvanic  excitability  and  the  degeneration  of  the  muscles  which  are 
not  present  in  the  cerebral  form  ;  in  the  latter  are  observed  various 
cerebral  symptoms.  The  position  of  the  disease  in  the  trunk  of  the 
nerve  may  be  determined  as  follows  :  paralysis  of  the  muscles  of  the 
face,  without  involving  taste,  indicates  with  other  symptoms  disease  of 
the  nerve  anterior  to  the  origin  of  the  chorda  tympani ;  paralysis  of 
the  muscles,  no  reaction  to  faradic  but  response  to  galvanic  current, 
paralysis  of  uvula,  indicate  lesion  of  the  nerve  at  the  origin  of  the  large 
superficial  petrosal  nerve  which  goes  to  the  spheno-palatine  ganglion, 
"When  there  is  alternating  paralysis,  the  lesion  is  most  probably  in  the 
pons.  If  partial  paralysis  exist,  the  velum  palati  being  affected  at  the 
same  time,  and  if  the  reflex  and  electrical  excitability  are  preserved, 
the  lesion  is  in  the  opposite  hemisphere  of  the  brain  or  its  crus. 

Treatment. — The  cause  of  pressure  on  the  nerve  within  the  cavity 
of  the  cranium,  or  disease  of  the  ear,  should  be  removed  if  practicable. 
In  all  doubtful  cases  a  course  of  iodide  of  potassium  should  be  pre- 
scribed. If  the  attack  is  of  the  rheumatic  variety — so  called — ^blisters 
to  the  mastoid  and  the  internal  use  of  pilocarpine  are  the  most  effec- 
tive measures.  The  application  of  electricity,  the  galvanic  current 
preferably,  should  be  begun  at  once,  and  continued  faithfully  until  a 
cure  is  effected  or  discovered  to  be  unattainable.  The  application 
should  be  made  by  one  pole — the  anode — on  the  mastoid,  and  the  cath- 
ode passed  over  the  terminal  filaments  of  the  nerve  as  distributed  to 
the  muscles. 

VASO-MOTOR  AND   TROPHIC   NEUROSES— HEMIORANIA—MI- 

GRAINE. 

Definition. — By  the  term  hemicrania  is  meant  a  unilateral  pain  in 
the  head,  irregularly  periodical,  and  accompanied  by  nausea  and  some- 
times vomiting,  and  excited  by  certain  reflex  disturbances.  By  the 
French  writers  it  is  termed  migraine,  which  has  been  naturalized  to  a 
large  extent  in  our  country,  and  it  is  known  in  common  language  as 
sich-headache. 

Causes. — Regarded  by  Romberg  as  an  hypersesthesia  of  the  brain, 
the  localization  of  the  disturbance  in  the  vaso-motor  system  was  first 
distinctly  affirmed  by  Du  Bois-Reymond,  who  maintained  that  the  cause 
of  the  affection  is  a  contraction  of  the  arterioles  on  the  affected  side 
of  the  head — a  fact  determined  by  observations  on  himself.  An  oppo- 
site view  of  the  state  of  the  sympathetic  was  taken  subsequently  by 
Mollendorff,*  who  maintained  that  the  vessels  are  relaxed.  As  is  often 
the  case,  the  truth  probably  lies  between  these  extremes,  as  Eulenberg  f 

*  "  Ueber  Hemikranie,"  Virchow's  "  Archiv,"  Band  xli,  s.  385. 
f  "  Nervenkrankheiten,"  op.  cit,  s.  116. 


HEMICRANIA.  643 

maintains.  Females  are  more  liable  than  males,  and  in  early  life  the 
disease  first  manifests  itself.  It  is  distinctly  inheritable,  or  at  least  the 
neuropathic  constitution. 

Symptoms. — The  disease  is  irregularly  paroxysmal,  and  in  the  inter- 
val between  the  attacks  there  is  no  pain  or  other  disturbance.  The 
paroxysms  may  or  may  not  be  preceded  by  prodromal  symptoms,  such 
as  weariness,  hebetude  of  mind,  etc.,  but  the  onset  of  the  attack  is 
usually  announced  by  chilliness,  nausea,  yawning,  and  general  muscu- 
lar soreness.  The  pain  comes  on  most  frequently  on  the  left  side,  and 
is  felt  in  gi'eatest  intensity  in  the  supra-orbital  ridge  and  in  the  eye, 
but  it  may  be  felt  nearly  equally  over  the  whole  side,  and  even  extend 
over  beyond  the  median  line  ;  usually  there  is  a  region  of  greatest 
severity  of  pain.  Tenderness  is  felt  when  the  cervical  ganglia — upper 
and  middle — are  pressed  on,  and  tenderness  is  also  experienced  when 
the  spinous  processes  of  the  last  cervical  and  first  dorsal  vertebrae  are 
subject  to  pressure.  The  sense  of  touch  is  more  acute  than  normal 
over  the  whole  area  of  the  hemicrania.  In  many  subjects  nausea  and 
vomiting  precede  the  attack  of  hemicrania  ;  in  others  the  pain  con- 
tinues for  some  time  before  nausea  is  experienced,  and  vomiting  often 
ends  the  attack.  Light  is  hurtful  to  the  eyes,  and  noises  to  the  ears. 
Rings  of  light  and  muscae  volitantes  float  before  the  eyes,  and  there 
are  noises  in  the  ears.  The  circulation,  temperature,  and  secretions  of 
the  affected  part  are  altered.  There  are,  as  Eulenberg  insists,  and  as 
the  author  has  repeatedly  observed,  two  kinds  of  disturbance  in  the 
circulation  :  contraction  of  the  vessels,  and  anaemia  of  the  affected 
part,  as  shown  in  pallor  of  the  face,  shrunken  eye  and  dilated  pupil  ; 
dilatation  of  the  vessels,  flushed  and  red  face,  the  conjunctivae  injected, 
and  the  pupil  contracted.  The  two  forms  may  coincide,  but  this  is 
rare,  and  there  may  be  cases  in  which  no  disturbance  exists  in  the 
sympathetic  ganglia. 

Course,  Duration,  and  Prognosis.— The  paroxysms  may  last  for  a 
few  hours  or  a  day  or  two.  They  may  occur  every  few  days,  every 
week,  or  every  month,  or  at  longer  intervals.  Women  are  especially 
liable  to  attacks  about  the  menstrual  period.  In  many  they  are  in- 
duced by  errors  of  diet.  As  the  pneumogastric  nucleus  lies  alongside 
of  the  nucleus  of  the  fifth,  it  is  easy  to  understand  the  transference  of 
sensations.  Usually  the  susceptibility  to  attacks  declines  with  the  ad- 
vance in  life  and  disappears  after  fifty.  The  author  has  frequently 
observed  that  the  disappearance  of  hemicrania  has  been  coincident 
with  the  occurrence  of  cerebral  haemorrhage.  Otherwise,  the  disease 
must  be  regarded  as  entirely  free  from  danger  to  life,  while  its  chief 
importance  lies  in  the  fact  that  few  cases  are  permanently  cured. 

Treatment. — The  most  important  point  is  a  careful  regulation  of 
the  diet  in  that  large  proportion  of  cases  originating  in  stomachal 
disorder.     An  easily  digested  aliment  of  the  nitrogenous  kind,  with 


644  DISEASES   OF   THE   KERVOUS   SYSTEM. 

decided  diminution  of  the  farinaceous  and  saccharine  elements,  is  the 
kind  of  diet  required.  In  these  cases  the  best  results  are  obtained 
from  the  use  of  arsenic — two  drops  of  Fowler's  solution  before  each 
meal,  kept  up  for  months.  In  the  other  group  of  cases,  nervous  in 
origin,  the  best  remedies  are  cuca,  guarana,  caffein,  and  bromide  of 
potassium.  The  last  mentioned  is  adapted  to  those  cases  dependent 
on  contraction  of  the  arterioles,  and  is  very  effective  if  administered 
just  before  the  onset  of  the  paroxysm,  in  a  sufficient  dose  (  3  ss.  —  3  j), 
and  repeated  several  times.  The  other  remedies  mentioned  are  better 
fitted  to  give  tone  to  the  sympathetic  ganglia  in  the  interval  between 
the  paroxysms.  When  there  is  anaemia,  a  chalybeate  course  is  highly 
serviceable.  When  the  moral  surroundings  are  such  as  to  cause  at- 
tacks, change  of  scene  is  highly  necessary.  If  the  disposition  to  the 
malady  is  inherited,  the  prophylaxis  is  very  important  and  should  in- 
clude diet,  exercise,  clothing,  and  the  avoidance  of  all  those  conditions 
which  tend  to  develop  an  abnormal  excitability  of  the  nervous  system. 
The  best  results  have  been  obtained  from  galvanization  of  the  superior 
ganglia  of  the  sympathetic  ;  the  positive  pole  over  the  ganglion  and 
the  negative  on  the  epigastrium  in  the  tetanic  form ;  and  the  poles 
reversed  in  the  paralytic  form.  Frommhold  *  has  obtained  the  best 
results  from  the  faradic  current. 


ANGINA    PECTORIS. 

Definition. — A  neurosis  of  the  heart,  in  which  there  occur  parox- 
ysms, characterized  by  pain  in  the  prsecordial  region,  extending  usu- 
ally into  the  left  shoulder  and  down  the  left  arm,  and  accompanied  by 
a  feeling  of  constriction  of  the  thorax,  and  a  strong  sense  of  impend- 
ing dissolution.     It  is  sometimes  called  neuralgia  of  the  heart. 

Causes. — A  predisposition  to  this  affection  seems  to  be  inherited. 
It  is  often  associated  with  chronic  cardiac  changes,  as  arteritis  of  the 
coronary  artery,  calcification  of  valves,  etc.  It  is,  as  Trousseau  first 
pointed  out,  sometimes  a  masked  epilepsy,  and  again  angina  pectoris 
may  alternate  with  epileptic  attacks.  It  may  occur  in  hysteria,  and 
may  precede  an  outbreak  of  mania.  Males  are  greatly  more  liable  to 
it  than  females,  and,  although  it  is  more  frequent  in  advanced  life, 
it  may  occur  at  any  age.  Excessive  smoking  by  young  and  nervous 
subjects  may  cause  it  at  a  comparatively  early  age. 

Pathological  Anatomy. — Various  changes  in  the  heart  are  found, 
but  these  are  accidental.  The  pathological  changes  which  stand  in  a 
causative  relation  to  the  attacks  are  those  of  the  cardiac  plexus  of  the 
phrenic  and  of  the  pneumogastric  nerves.  Pressure  of  enlarged  lym- 
phatics, inflammation  of  parts  of  the  cardiac  j^lexus,  with  changes  in 
the  coronary  artery,  seem  to  be  the  most  constant  (Eulenberg). 

*  "Die  Migraine  unci  ihre  Ileilung  durch  Electricitiit,"  Pesth,  1868,  p.  115. 


ANGINA  PECTORIS.  645 

Sjrmptoins. — Angina  pectoris  is  a  paroxysmal  affection,  the  attacks 
occurring  irregularly,  and  in  the  interval  there  are  no  symptoms.  The 
attacks  are  eminently  characteristic.  The  patient  is  suddenly  seized, 
it  may  he  in  the  night,  during  exercise  or  while  resting,  with  an  in- 
tense pain  in  the  praecordial  region,  accompanied  by  a  sense  of  con- 
striction and  suffocation.  He  at  once  assumes  a  fixed  position  as  if 
the  least  movement  would  cost  him  his  life  ;  his  face  becomes  deadly 
pale,  and  a  cold  sweat  bedews  the  skin.  The  pain  shoots  across  the 
chest,  upward  under  the  sternum  and  toward  the  left  shoulder,  and 
down  the  left  arm.  The  sudden  pain  and  terror  may  cause  syncope, 
but  usually  the  pain  ceases  in  a  few  seconds  or  minutes,  and  the  pa- 
tient takes  a  deep  breath  with  a  sigh  of  relief.  The  respiration  may 
continue  undisturbed,  may  be  very  much  oppressed,  or  it  may  be 
arrested,  simply  from  a  fear  that  the  least  movement  may  end  life. 
The  pulse  is  small,  the  action  of  the  heart  weak  or  arrested,  and  the 
arterial  tension  very  high.  A  decided  contraction  of  the  superficial 
arterioles  causes  the  skin  to  assume  a  pallid  appearance,  and  a  sudden 
chilliness  with  chattering  of  the  teeth  occurs.  When  the  attack  is 
over,  the  circulation  becomes  active,  the  skin  warm,  eructation  of  gas, 
sometimes  vomiting,  occurs,  and  a  quantity  of  pale,  watery  urine  is 
passed. 

Course,  Duration,  and  Termination. — The  course  of  the  disease  is 
chronic.  The  paroxysms  have  a  variable  duration — usually  lasting  a 
few  seconds  only,  but  they  may  continue,  with  remissions  in  the  sever- 
ity of  the  symptoms,  for  hours,  even  days.  The  return  of  the  attacks 
is  irregular  and  uncertain  ;  they  may  appear  after  an  intermission  of 
days,  or  weeks,  or  months.  It  is  usually  several  months  after  the 
occurrence  of  the  first  seizure  until  the  next  appears.  The  nocturnal 
attacks  are  spontaneous  in  origin,  but  those  occurring  during  the  day 
are  caused  by  some  strong  emotion — a  fit  of  anger,  chagrin  or  disap- 
pointment— ^by  some  active  exercise,  or  by  indigestion.  The  disease 
may  occur  irregularly  during  five  to  seven  years.  The  importance  of 
angina  is  largely  affected  by  the  cardiac  lesions  which  usually  accom- 
pany it,  and  the  fatal  termination  so  often  observed  after  two  or  three 
paroxysms,  rarely  in  the  first,  is  due  to  these  associated  cardiac  lesions. 
Whether  symptomatic  or  essential,  angina  pectoris  is  a  fatal  malady, 
but  the  latter  form  is  more  amenable  to  treatment,  and  offers  a  longer 
duration  than  the  former. 

Treatment. — All  causes  of  disturbance  of  the  cardiac  action,  as 
tobacco-smoking,  etc.,  must  be  removed.  Those  attacks  accompanied 
by  vascular  spasm — and  this  seems  to  be  the  case  during  the  paroxysm 
in  all  cases — are  most  promptly  relieved  by  the  nitrite  of  amyl,  oi'igi- 
nally  proposed  by  Brunton.  Patients  should  be  provided  with  the 
perls  containing  three  minims,  to  be  broken  in  the  handkerchief,  and 
the  vapor  inhaled  on  the  instant.     This  expedient  has  given  relief  in  a 


Q^Q  DISEASES   OF   THE   NERVOUS   SYSTEM. 

large  number  of  cases.  A  great  variety  of  remedies  have  been  pro- 
posed to  prevent  the  seizures.  Full  doses  of  arsenic  (ten  minims  of 
Fowler's  solution)  three  times  a  day,  after  meals,  have  had  good  effects. 
The  hypophosphites  and  cod-liver  oil,  continued  steadily  for  months, 
have  done  good  in  debilitated'  subjects.  Where  a  malarial  influence 
may  be  presumed  to  exist,  quinia  is  the  proper  remedy.  When  epi- 
lepsy is  masked  under  attacks  of  angina,  bromide  of  potassium  affords 
great  relief.  Remarkably  good  results  have  been  obtained  from  gal- 
vanism, stabile  currents  being  used — the  positive  pole  at  the  prsecordia, 
and  the  negative  over  the  seventh  cervical  vertebra.  The  good  has 
been  accomplished  in  the  examples  of  essential  angina  pectoris. 


EXOPHTHALMIC  GOITRE    (GRAVES'S   DISEASE). 

Definition. — Exophthalmic  goitre  is  a  disease  characterized  by  a 
quaternary  of  symptoms — exof)hthalmus,  enlarged  thyroid,  dilatation 
of  the  arteries,  and  palpitation  of  the  heart.  It  has  received  a  variety 
of  designations.  In  Germany  it  is  known  as  Basedow's  disease ;  in 
England,  Graves's  disease,  from  the  names  of  supposed  discoverers. 

Causes. — Although  a  variety  of  causes  have  been  alleged,  few  are 
worthy  of  serious  consideration.  Heredity,  anaemia,  and  chlorosis, 
moral  emotions,  have  been  considered  causative,  but  of  these  only  the 
last  appears  to  have  exerted  any  real  influence.  In  the  cases  seen  by 
the  author,  fright,  chagrin,  reverses  of  fortune,  etc.,  were  the  causes, 
but  it  is  probable  that  the  effect  produced  was  really  due  to  some  pe- 
culiar condition  of  the  nervous  system.  This  disease  is  more  common 
in  women  than  in  men — in  the  former  before,  in  the  latter  after  thirty^ 
whence  it  may  be  concluded  that  a  mobile  nervous  system  is  neces- 
sary to  its  origin. 

Pathological  Anatomy. — The  changes  characteristic  of  exophthal- 
mic goitre  are  by  no  means  striking.  The  veins  and  arteries  of  the 
thyroid  show  great  increase  of  size  and  thickness,  and  the  gland 
itself  is  unaltered,  or  in  the  condition  of  simple  hyperplasia,  or  cystic  ; 
but  the  last-mentioned  state  has  no  relation  to  this  disease.  A  consid- 
erable increase  in  the  fat  behind  the  eye  has  been  observed  ;  the  mus- 
cles are  affected  with  fatty  degeneration  (one  case)  ;  the  ophthalmic  ar- 
tery is  atheromatous  (one  case) — but  these  are  probably  only  accidental 
changes.  Some  structural  alterations  have  been  found,  in  a  majority 
of  cases,  in  the  sympathetic  ganglia,  and  especially  in  the  inferior  gan- 
glion. Both  sides  may  be  affected,  or  one  only,  and  the  amount  of 
disease  varies  greatly.  The  heart  in  most,  if  not  all,  cases  is  damaged 
variously,  but  these  changes  are  not  a  part  of  this  disease,  and  are  en- 
tirely accidental. 

Symptoms. — In  one  of  the  author's  cases  the  first  symptom  (pro- 
trusion of  the  eyes)  was  perceived  by  the  patient  on  going   to  the 


EXOPHTHALMIC   GOITRE.  ^47 

mirror  in  the  morning.  Slie  had  been  subjected  to  a  great  shock  the 
previous  evening.  Usually  the  onset  of  the  disease  is  gradual,  so  that 
there  are  really  two  types,  the  acute  and  chronic.  The  acute  cases 
may  run  their  whole  course  in  a  few  months.  The  initial  symptom 
may  be  any  one  of  the  four  great  charactei'istics,  but  palpitation  is 
most  often  the  first  departure  from  health.  The  increased  action  of 
the  heart  is  at  first  paroxysmal,  with  intei'missions  during  which  the 
rate  is  normal  ;  but  the  intervals  shorten  until  the  heart-beat  is  always 
above  normal,  with  paroxysms  during  which  marked  acceleration  takes 
place.  When  the  acceleration  attains  its  maximum,  the  ordinary  rate 
is  from  90  to  120,  but  during  the  exacerbations  160,  even  200,  may  be 
reached.  A  soft-blowing  murmur  is  usually  audible  at  the  base,  and 
propagated  along  the  great  vessels,  and  a  stronger,  whirring,  blowing 
murmur  is  to  be  heard  over  the  carotids  and  the  thyroid  ;  an  epigas- 
tric and  sometimes  hepatic  pulsation  may  be  detected.  The  vessels 
of  the  neck  and  of  the  thyroid  may  be  felt  pulsating  strongly,  the 
thyroid  almost  as  an  aneurism.  The  gland  enlarges,  one  lobe — the 
right  in  the  author's  experience  (six  cases) — twice  as  often  as  the 
left ;  but  ultimately  the  whole  of  the  organ,  in  several  months  usually, 
after  the  increased  pulsations  have  begun.  In  very  rare  cases  no  en- 
largement of  the  thyroid  has  occurred.  Sometimes  the  goitre  is  the 
first  symptom  observed.  It  is  elastic,  rather  soft,  and  has  a  distinct 
thrill  like  that  of  an  aneurism.  It  never  attains  a  very  great  size, 
reaches  its  maximum  in  a  few  days  or  weeks,  and  fluctuates  greatly  in 
its  dimensions.  During  the  exacerbations  in  the  action  of  the  heart  it 
enlarges,  and  subsides  correspondingly  after  the  attack  is  over.  After  a 
time  it  becomes  firmer,  and  remains  uniform  in  size.  This  change  is 
due  to  the  fact  that  the  variations  in  the  volume  of  the  gland  are  pro- 
duced by  the  varying  caliber  of  the  vessels,  and,  when  hyperplasia  of 
the  gland-elements  occurs,  the  fluctuations  in  size  are  no  longer  possi- 
ble. Very  great  changes  in  the  thyroid  may  take  place,  due  entirely 
to  accidental  causes.  Thus  it  enlarges  in  pregnancy,  and  it  may  take 
on  cystic  and  calcareous  degeneration.  Exophthalmus  may  be  the  first 
symptom,  as  in  one  of  the  author's  cases,  but  usually  this  comes  on 
after  the  goitre.  It  may  begin  in  one  eye,  but  it  is  very  rarely  con- 
fined to  one,  and  usually  one  eye  protrudes  more  than  the  other.  It 
may  not  occur  at  all  in  a  case  otherwise  well  marked,  but  this  is  un- 
usual. The  degree  of  protrusion  varies  from  a  slight,  staring  expres- 
sion to  the  actual  dislocation  of  the  eye  on  the  cheek,  and  it  increases 
during  the  paroxysms  of  active  palpitation,  and  diminishes  in  the  inter- 
val. A  very  important  diagnostic  point  is  the  incoordination  in  the 
movements  of  the  upper  eyelid  and  of  the  ocular  globe.  If  a  patient 
be  told  to  look  at  her  feet,  the  upper  lid,  it  will  be  seen,  does  not  fol- 
low the  movement  of  the  globe.  As  this  does  not  obtain  in  the  exoph- 
thalmus from  any  other  cause,  and  as  it  may  be  present  early  in  the 


648  DISEASES  OF  THE  NERVOUS  SYSTEM. 

history  of  the  case,  it  may  be  very  important.  The  nutrition  of  the 
cornea  may  suffer  and  conjunctivitis  is  an  ordinary  complication. 
More  or  less  fever  occurs  during  the  course  of  this  disease,  and  a  very 
considerable  subjective  sense  of  heat  is  felt.  The  rise  of  temperature 
is  from  one  to  three  degrees  of  Fahrenheit,  and  a  considerable  increase 
of  sweat  is  observed.  Pigment  deposits  and  pityriasis  versicolor  have 
been  observed  by  the  author  in  some  cases,  and  other  trophic  affections 
of  the  skin  have  been  reported  by  Bulkley,  of  New  York.  Changes 
in  the  disposition  are  constantly  observed.  The  subjects  of  this  dis- 
ease are  nervous,  apprehensive,  irritable,  and  lachrymose.  Vertigo, 
wakefulness,  tremors,  headache,  impaired  memory  and  power  of  appli- 
cation are  often  experienced.  The  appetite  is  usually  poor,  digestion 
feeble,  vomiting  readily  occurs,  and  a  more  or  less  rapid  decline  in 
flesh  and  strength  takes  place.  A  marked  degree  of  pallor  is  usually 
observed.  The  blood  is  anasmic,  and  amenorrhcea  is  present  in  most 
cases. 

Course,  Duration,  and  Termination. — Acute  cases  going  through  a 
full  development  and  decline  in  a  few  months  are  very  exceptional. 
It  is  an  essentially  chronic  malady,  and  years  are  occupied  in  its  vary- 
ing phases.  Recovery  may  ensue  within  six  months,  but  usually  it 
is  not  complete,  and  the  symptoms  develop  again.  The  most  impor- 
tant lesions  occurring  are  dilatation  of  the  cavities  of  the  heart,  and 
death  is  the  ultimate  result  of  the  disturbances  in  the  circulation. 
Tuberculosis  is  apt  to  supervene,  and  some  cases  are  carried  off  by 
intercurrent  inflammatory  aifections.  A  favorable  termination  may  be 
looked  for  when  the  general  health  is  good,  the  thyroid  unchanged, 
except  by  simple  hyperplasia,  and  the  heart  is  sound. 

Treatment. — The  usual  arterial  sedatives  possess  but  small  value  in 
the  treatment  of  this  disease.  Good  results  have  been  obtained  from 
belladonna  and  ergot.  They  should  be  administered  for  several  months, 
and  in  full  doses.  The  anaemia,  which  is  so  pronounced  a  symptom, 
requires  iron.  Traube  achieved  great  success  by  a  combination  of 
quinia  and  iron.  The  author  has  had  good  effects  from  quinia,  bella- 
donna, and  ergotin,  in  combination.  Galvanization  of  the  cervical 
sympathetic  and  the  pneumogastric,  by  placing  the  anode  under  the 
the  ear  and  the  cathode  at  the  epigastrium,  the  author  has  found  to  be 
of  the  highest  efficiency.  While  the  current  is  passing,  the  action  of 
the  heart  becomes  less  tumultuous,  the  protrusion  of  the  eyes  dimin- 
ishes, and  the  thyroid  shrinks  somewhat.  Besides  the  stabile  applica- 
tion just  indicated,  labile  applications  should  be  made  over  the  thy- 
roid, and  a  weaker  current  should  be  applied  to  the  eyes.  While  the 
galvanic  applications  are  making,  the  remedies  suggested  may  be  used 
internally. 


GENERAL  OR  COiNSTlTUTIOML  DISEASES. 


ERUPTIVE   EEYERS. 


VARIOLA. 


Definition. —  Variola  is  an  eruptive  disease  characterized  by  the 
presence  of  pustules,  which  make  their  appearance  at  the  end  of  the 
third  exacerbation  of  the  initial  fever,  when  the  temperature  declines, 
but  this  period  of  diminished  fever  or  of  apyrexia  is  followed  by  a  sec- 
ondary fever,  or  fever  of  maturation.  Small-jyox,  or  pock,  is  the  name 
in  common  use,  which  was  formerly  employed  in  contradistinction  to 
the  big  pocJc,  or  syphilis — the  word  "  pock  "  meaning  pustide. 

Causes. — Small-pox  prevails  under  all  conditions  of  soil  and  cli- 
mate, its  distribution  at  the  present  time  being  regulated  by  the  de- 
gree of  protection  afforded  by  vaccination.*  It  occurs  at  all  ages, 
and  even  the  fmtus  in  utero  is  attacked,  and  it  may  be  so  early  as  the 
fourth  or  fifth  month  of  utero-gestation.  Both  sexes  appear  to  be 
equally  susceptible.  Race  exercises  an  influence  which  is  quite  de- 
cided— the  dark  races,  negroes  especially,  possess  a  peculiar  liability. 
During  the  actual  existence  of  typhoid  fever,  scarlet  fever,  and  measles, 
there  is  an  immunity  against  the  small-pox  poison,  and  the  susceptibil- 
ity of  individuals  varies  at  different  times.  As  a  rule,  those  who  have 
been  attacked  once  possess  complete  protection  against  future  seizures, 
but  there  are  numerous  exceptions.  The  author  has  met  with  examples 
of  small-pox  occurring  twice  and  three  times  in  the  same  individuals, 
and  notwithstanding  vaccination.  The  susceptibility  to  a  new  attack 
may  be  acquired  in  a  few  months,  but  usually  not  until  many  years 
have  elapsed.  Mild  attacks  are  apparently  less  protective  than  severe 
ones  against  future  recurrence  of  the  disease.  Small-pox  is  spread  by 
a  peculiar  virus  whose  nature  is  unknown.  It  is  true,  minute  organ- 
isms on  which  the  toxic  activity  is  supposed  to  depend  have  been  found 
in  vaccinia,  and  also  in  the  pustules  of  variola,  but  their  position,  as 

*  "Traite  de  Climatologie  Medicale,"  op.  cit.,  vol.  iv,  p.  370. 


650  EEUPTIYE   FEYERS. 

accidental  or  causative,  has  not  yet  been  made  out.  The  transparent 
fluid  of  the  pustules,  before  it  becomes  yellow  and  turbid,  is  most 
active,  but  the  dried  pustules  are  only  less  active.  The  morbific  prin- 
ciple is  not  confined  to  the  patient,  but  diffuses  in  the  atmosphere  about 
him,  and  extends  a  variable  distance.  Ventilation  and  large  air-space 
dilute  the  poison  ;  hence  a  close  room,  with  a  number  of  persons, 
especially  having  small-pox,  occupying  it,  concentrates  the  poison, 
making  communication  more  certain.  There  is  no  period,  from  the 
initial  fever  to  the  final  desquamation,  at  which  the  disease  may  not 
be  communicated  to  the  susceptible,  but  the  stage  of  suppuration  is 
the  most  virulent.  All  articles  which  have  been  about  the  person  or 
bedding  of  the  patient,  especially  those  having  a  rough  surface  to 
which  it  may  adhere,  may  retain  the  poison  for  a  long  time,  and  it 
may  be  conveyed  from  the  patient,  and  from  his  bedding  or  clothing,  to 
the  clothing  of  another.  The  bodies  of  those  dead  of  variola  com- 
municate the  disease,  probably  until  the  virus  is  destroyed  by  putre- 
factive decomposition.  The  persistence  in  the  activity  of  the  poison 
and  its  power  to  resist  external  influences  are  very  great.  When  pre- 
served from  the  contact  of  air,  it  retains  its  activity  for  months  and 
years.  The  spread  of  small-pox  is  affected  by  the  immunity  derived 
from  attacks  of  the  disease,  but  especially  by  the  protective  influence 
of  vaccination.  The  exemption  derived  by  the  latter  is  less  perma- 
nent than  the  former,  and  in  many  cases  terminates  after  some  years. 
It  happens  in  this  way  that  every  few  years  a  part  of  the  population 
of  civilized  communities  reacquire  their  susceptibility  to  the  poison, 
and  furnish  the  material  for  an  epidemic. 

Pathological  Anatomy. — The  most  important  changes  are  those  con- 
cerned in  the  formation  of  the  pustules.  The  first  step  is  the  appear- 
ance of  a  small  hypersemic  spot  in  the  entire  thickness  of  the  derma,  at 
and  through  a  papilla.  A  swelling  ensues  in  the  part,  especially  in  the 
outer  layer  of  cells  of  the  papilla,  and  pushing  up  the  epidermis  forms  a 
papule.  An  exudation  of  a  transparent  fluid  now  takes  place  from  the 
papillary  layer,  which,  pushing  aside  the  cells  and  the  epidermis  above, 
forms  a  vesicle.  The  cells  are  separated  into  groups,  and  not  from  each 
other,  are  compressed  by  the  exudation,  form  an  apparent  network, 
in  the  meshes  of  which  the  lymph  is  contained.*  While  the  upper 
cells  of  the  papilla  and  the  epidermis  are  engaged  in  the  formation  of 
the  vesicle,  the  papillae  themselves  are  swollen  by  enlarged  and  tor- 
tuous vessels,  and  by  an  exudation  of  serum.  A  central  depression — 
an  umbilication — forms  in  the  vesicle,  which  is  perforated  by  a  hair- 
follicle,  or  the  duct  of  a  sweat-gland.  This  is  due  to  the  fact  that  the 
epidermis  is  continuous  with  the  hair-follicle,  and  the  duct  of  the 
sweat-gland  also,  so  that  this  portion  of  the  vesicle  can  not  rise — in 

*  "  Untersuchungen  zur  Anatomie  des  Blatternprozesses,"  von  Dr.  H.  Anspitz  uud  Dr. 
S.  Basch,  in  Virchow's  "  Archiv,"  Band  xxviii,  p.  337,  et  seq. 


VARIOLA.  651 

fact,  the  accumulation  takes  place  around  it — whence  it  follows  that  a 
central  depression  must  exist.  Pocks  without  being  so  situated — not 
perforated  by  a  hair-follicle  or  sweat-gland — also  have  this  umbilica- 
tion.  Under  these  circumstances,  we  may  adopt  the  explanation  of 
Anspitz  and  Basch,  who  hold  that  this  appearance  is  due  simply  to  the 
more  rai)id  swelling  of  the  periphery  of  the  pustule.  When  fully  ripe 
the  umbilication  disappears,  to  reappear  again  in  drying,  owing  to  the 
more  rapid  desiccation  of  the  center.  In  the  case  of  confluent  variola, 
the  adjacent  papilla  may  become  inflamed,  and  partial  necrobiosis  oc- 
cur, causing  great  destruction  of  tissue.  There  is  nothing  peculiar 
and  distinctive  in  the  haemorrhagic  form,  this  condition  being  due 
merely  to  the  substitution  of  blood  for  serum.  The  haemorrhage  may 
be  confined  to  the  pustules,  or  may  extend  into  the  neighboring  pa- 
pilla, and,  in  the  worst  cases,  the  whole  cutis  and  subcutaneous  tissue 
may  be  infiltrated  with  blood.  Pustules  are  formed  on  the  mucous 
membrane,  and  simultaneously  catarrhal,  croupous,  or  diphtheritic  in- 
flammation takes  place.  The  mucous  membrane  nearest  the  external 
skin,  and  most  exposed,  is  most  certainly  and  severely  affected.  The 
nose,  tongue,  tonsils,  palate,  and  pharynx,  and  the  orifice  and  internal 
portion  of  the  Eustachian  tube,  are  more  or  less  infiltrated  with  pus  ; 
the  tongue  loses  its  epithelium  to  a  considerable  extent,  and  pustules 
extend  down  the  trachea  to  the  bifurcation,  and  also  to  a  short  dis- 
tance down  the  cesophagus.  The  liver,  spleen,  kidneys,  and  heart  are 
affected  by  granular  and  fatty  degeneration,  and  in  the  hsemorrhagic 
form  there  are  numerous  haemorrhages  and  ecchymoses  throughout 
the  body — in  the  serous  and  mucous  membranes,  and  in  most  of  the 
viscera. 

Symptoms. — The  period  intervening  between  the  reception  of  the 
materies  morbi  and  the  outbreak  of  the  malady  is  called  the  period  of 
incubation.  This  is  not  a  fixed  period,  although  tolerably  constant, 
the  variations  being  due  probably  to  the  differences  in  susceptibility, 
to  the  action  of  the  poison.  The  most  usual  period  of  incubation  is 
from  ten  to  thirteen  days  (Curschmann),  which  is  the  time  generally 
agreed  on  by  the  authorities,  but  in  some  instances  it  has  been  as 
short  as  five  and  as  long  as  fourteen  days.  During  the  stage  of  incu- 
bation we  may  suppose  that  the  multiplication  of  the  poison  is  taking 
place,  but  there  are  no  objective  nor  subjective  sensations  indicative 
of  the  process  until  the  stage  of  invasion.  This  stage  sets  in  suddenly 
with  a  violent  rigor,  only  comparable  to  that  of  an  intermittent,  or  of 
pneumonia.  Sometimes  there  are  several  chills  or  several  hours  of  chil- 
liness. Fever  begins  at  once,  and  in  a  short  time  rises  to  103°  or  104'^ 
Fahr.,  at  which  it  continues,  there  being  a  slight  morning  remission. 
The  fever  may  rise  higher  after  the  first  day,  to  10.5°,  even  106°,  and 
continue  at  that  rate  until  the  period  of  eruption.  The  pulse  is  strong, 
full,  and  bounding,  and  ranges  in  adults  from  100  to  140  ;  in  children 


652  ERUPTIVE  FEVERS. 

to  160.  The  action  of  the  heart  is  strong  and  heaving,  there  is  some 
difficulty  of  breathing,  often  considerable  dyspnoea  is  present,  the  ca- 
rotids beat  vehemently,  the  face  is  red,  the  eyes  injected  ;  there  are  an 
intense  headache  and  sleeplessness,  or  sleep  is  disturbed  by  frightful 
dreams.  Appetite  is  entirely  absent,  thirst  is  incessant,  and  nausea 
and  vomiting  with  constipation  usually  occur.  There  is  present  in 
all  cases  more  or  less  pain  in  the  back,  but  in  the  largest  number  this 
takes  the  form  of  agonizing  suffering,  the  pain  being  at  the  same  time 
acute,  lancinating,  shooting  down  through  the  hips  and  thighs  into 
the  lower  limbs,  and  heavy,  tensive,  boring  pain  felt  deeply  in  the 
spine.  The  pronounced  backache  is  accompanied  by  the  equally  pro- 
nounced headache,  which  possesses  similar  characteristics.  There  may 
be  some  confusion  of  mind  in  the  milder  cases  occurring  toward  even- 
ing, and  in  other  cases  active  delirium,  especially  in  subjects  ad- 
dicted to  alcoholic  excess.  It  was  a  dictum  of  Sydenham,  revived  by 
Trousseau,  that  the  mildness  and  shortness  of  the  stage  of  invasion 
furnished  a  guide  to  the  character  of  the  attack.  "  When  the  erup- 
tion makes  its  appearance  at  the  end  of  the  second  day  or  the  be- 
ginning of  the  third,  it  is  necessarily  confluent ;  when  it  appears  at 
the  end  of  three  and  a  half  to  four  full  days,  or  is  postponed  to  the 
fifth,  it  is  certainly  discrete  "  ( Jaccoud).  Although  there  is  a  mea- 
sure of  truth  in  the  former  propositions,  they  are  by  no  means  exact. 
The  author  agrees  with  the  dictum  of  Jaccoud.  If  the  eruption  ap- 
pears after  four  full  days  of  the  preliminary  fever,  it  is  never  conflu- 
ent ;  it  is  either  discrete  or  coherent.  Although  definite  conclusions  as 
to  the  severity  of  the  disease  can  not  be  drawn  from  the  date  of  the 
appearance  of  the  eruption,  yet  the  severity  of  the  symptoms  during 
the  stage  of  invasion  does  furnish  a  measure  of  the  probable  violence 
of  the  disease.  Besides  the  regular  phenomena  belonging  to  the  stage 
of  invasion,  there  are  certain  inconstant  symptoms  which  possess  a  high 
degree  of  importance.  These  are  convulsions,  delirium,  and  dyspnoea, 
which  have  been  briefly  referred  to,  and  certain  initial  or  prodromal 
rashes  which  have  not  thus  far  been  discussed.  Following  the  divi- 
sion of  Curschmann,  these  rashes  may  be  arranged  in  two  groups,  ery- 
thematous and  hcemorrhagio.  The  erythematous  form  is  general  to 
the  whole  surface,  and  assumes  either  a  scarlatinal  or  rubeolous  appear- 
ance. The  haemorrhagic  eruption  consists  of  minute  points  of  hemor- 
rhagic extravasation  into  the  epidermis.  When  these  are  combined, 
the  hsemorrhagic  spots  appear  like  petechise  or  an  erythema.  The 
favorite  site  for  these  initial  rashes  is  the  lower  portion  of  the  abdo- 
men, the  genitals  and  thighs  forming  a  triangle  which  has  been  desig- 
nated the  triangle  of  Simon.  "  A  brachial  triangle  "  is  formed  of  the 
rashes  along  the  side  of  the  trunk,  extending  into  the  axilla,  the  inner 
side  of  the  arm,  and  over  the  pectoral  muscles.  The  erythematous  erup- 
tions tend  to  spread  over  the  whole  surface  of  the  body.     These  erup- 


VARIOLA.  653 

tions  or  rashes  of  the  stage  of  invasion  are  by  no  means  constant  in 
their  appearance  ;  many  cases  and  some  epidemics  are  entirely  free  of 
them.  In  the  last  epidemic  of  small-pox,  the  author,  then  practicing 
at  Cincinnati,  saw  a  number  of  them,  and  it  was  common  to  hear  re- 
ports of  cases  in  societies  of  the  coincident  appearance  and  develop- 
ment of  scarlet  fever  or  measles  and  small-pox.  They  usually  appear 
on  the  second  day,  but  they  may  appear  on  the  first  or  third.  Their 
duration  is  short,  the  erythematous  lasting  from  twelve  to  twenty-four 
hours,  the  hoamorrhagic  a  day  or  two  or  longer.  The  invasion  stage  of 
variola  is  sometimes  diversified  by  the  appearance  of  the  haemorrhagic 
condition  or  diathesis  {jnirpxira  variolosa),  and  this  is  often  confound- 
ed with  the  comparatively  innocent  hsemorrhagic  rash.  Purpura  vari- 
olosa sets  in  in  the  usual  way  with  severe  rigor  and  pains  in  the  head 
and  back,  very  high  fever,  and  great  prostration.  In  from  eighteen  to 
thirty-six  hours  a  very  intense  scarlatinif  orm  eruption  spreads  all  over 
the  body  except  the  face.  Petechia3  and  considerable  patches  of  hsem- 
orrhage  appear  in  the  skin  and  vary  in  size  from  mere  points  to  an 
irregularly  rounded  figure  about  an  inch  in  diameter,  which  remain  dis- 
crete or  apart  on  the  extremities,  and  confluent  on  the  abdomen,  form- 
ing irregular  masses.  The  face  swells  and  is  red  ;  the  conjunctivae 
are  injected,  and  the  eyes,  apparently  sunken  in  their  orbits,  are  sur- 
rounded by  large,  dark  rings  formed  by  the  effusion  of  blood  into  the 
lids.  The  tongue  is  swollen  and  coated  with  a  heavy,  yellowish  fur, 
and  the  pharynx,  tonsils,  and  palate  are  covered  with  a  membranous 
exudation,  which  emits  a  horrible  odor.  A  severe  cough,  with  watery 
and  bloody  expectoration,  comes  on,  and  there  are  nausea  and  vomiting, 
with  bilious  and  bloody  evacuations,  and  offensive  bloody  stools.  The 
urine  contains  a  large  amount  of  albumen,  which  presently  becomes 
bloody  and  thick.  If  pregnancy  exist,  miscarriage  takes  place,  and 
the  patient  is  carried  off  with  the  severe  and  uncontrollable  hoemorrhage. 
The  mind  usually  remains  unaffected,  though  there  may  be  delirium 
and  coma,  and  death  ensues  somewhere  from  the  third  to  the  sixth  day 
after  the  attack  began.  The  body  has  a  frightful  appearance  at  and 
immediately  subsequent  to  death  ;  it  turns  black  and  is  bloated,  the 
features  being  horribly  distorted  and  swollen.  In  such  cases  death 
appears  before  the  eruption  can  develop,  or  it  is  so  obscured  as  not  to 
be  recognizable. 

Stage  of  Eruption. — The  characteristic  eruption  makes  its  appear- 
ance at  the  end  of  the  third  exacerbation  of  the  fever — usually  on  the 
evening  of  the  third  or  the  morning  of  the  fourth  day — and  is  seen  first 
on  the  forehead,  about  the  eyes  and  mouth,  on  the  hairy  scalp,  and 
then  extends  to  the  body  and  the  extremities.  The  eruption  at  first 
consists  of  a  red  point,  effaced  by  pressure,  slightly  elevated,  some- 
what hard,  and  rolling  under  the  finger  like  a  small  shot  in  the  skin. 
The  manner  of  distribution  of  the  eruption  varies  somewhat.     There 


654 


ERUPTIVE   FEVERS. 


are  four  forms  in  which  the  eruption  may  be  arranged  :  the  discrete, 
or  each  pustule  separate  and  distinct ;  the  corymhic,  or  placed  in  clus- 
ters or  patches  ;  the  coherent,  in  which  the  individual  pustules  come  in 
contact ;  and  the  confluent,  in  which  the  pustules  unite  or  flow  together 
without  a  line  of  division  between  them.  In  the  ordinary  typical  case, 
the  eruption  is  completed  and  no  new  pustules  make  their  appearance 
after  twenty-four  to  thirty-six  hours.  They  tend  to  locate  about  the 
hair-follicles,  the  orifices  of  the  sebaceous  and  of  the  sudoriparous  glands. 
On  the  second  day  of  the  eruption,  and  the  fifth  day,  including  the 
initial  stage,  the  red  point  is  enlarged  and  elevated  into  a  papule.  On 
the  third  day  of  the  eruption  the  papules  are  transformed  into  vesicles 
filled  with  a  transparent,  serous  fluid  ;  the  vesicles  increase  in  size  dur- 
ing the  next  day  or  day  and  a  half,  and  on  the  fifth  day  of  the  erup- 
tion, and  the  eighth  day  of  the  disease,  the  serous  fluid  of  the  vesicle 
becomes  milky  and  presently  purulent.  When  the  vesicle  is  fully  de- 
veloped, a  central  depression  or  umbilicus  appears,  and  at  the  bottom 
is  seen  a  hair-follicle,  or  duct  of  a  sweat  or  sebaceous  gland,  but  many 
distinctly  umbilicated  are  not  around  a  hair-follicle  or  gland-duct,  show- 
ing that  this  appearance  is  in  part  due  to  the  more  rapid  development 
of  the  peripheral  portion,  as  suggested  by  Anspitz  and  Basch.  If  the 
summit  of  the  vesicle  which  now  appears  milky  be  punctured,  a  drop 
only  of  fluid  will  escape,  because  of  the  cellular  arrangement  of  the 
body  of  the  pustule.  While  the  appearance  of  the  eruption  does  not 
indicate  suppuration  in  all  the  forms,  except  the  confluent,  until  the 


Fig.  40. — Eange  of  Temperature  in  Discrete  Variola. 

eighth  day,  the  fever  of  suppuration  really  begins  on  the  seventh.  In 
the  confluent  and  the  extensive  coherent  forms,  the  fever  of  suppura- 
tion may  set  in  on  the  sixth  day  of  the  period  of  eruption..  There 
may  be,  therefore,  considerable  variation  in  the  duration  of  the  stage 
of  eruption. 

In  the  discrete  form,  a  marked  change  takes  place  in  the  condition 


VARIOLA. 


655 


of  the  patient  when  the  eruption  appears.     The  intolerable  headache 
and  backache  subside  or  disappear  entirely,  the  fever  abruptly  falls 


Fig.  41.— Coherent  Variola. 


to  normal,  even  slightly  below  it,  the  nausea  ceases,  and  the  patient 
within  a  few  hours  passes  from  a  condition  of  great  suffering  to  one  of 
comfort.  It  is  only  in  cases  of  varioloid,  or  of  variola,  with  few  pus- 
tules, that  the  defervescence  is  so  sudden.  In  the  more  severe  discrete 
cases,  or  coherent,  the  decline  of  temperature,  although  considerable, 
does  not  reach  the  normal,  and  occupies  a  day  or  two  of  a  remittent 
type,  with  considerable  exacerbations.  In  the  confluent  form  there  is  a 
mere  abortive  attempt  at  decline  of  temperature  without  much  change. 
The  pulse  falls  correspondingly  to  the  decline  of  fever.  An  eruption 
appears  on  the  mucous  surfaces  simultaneously  with  that  on  the  skin  : 
on  the  conjunctiva,  pharynx,  larynx,  and  trachea,  and  causing  lachry- 
mation,  photophobia,  difficulty  in  swallowing,  and  cough.  In  confluent 
cases  the  eruption  may  extend  to  the  bronchi,  to  the  intestine,  urethra, 
and  vagina.  Very  serious  results  may  be  derived  from  the  pustules  in 
these  situations.  Besides  the  symptoms  above  mentioned,  there  may 
be  a  violent  conjunctivitis,  ulceration  of  the  cornea  and  staphyloma, 
with  intense  photophobia  ;  constant  flow  of  saliva,  and  dysphagia  ; 
toneless  voice,  croupy  cough,  and  suffocative  attacks  ;  dysenteric  dis- 
charges ;  painful  urination  ;  and  a  sense  of  burning  in  the  vulva  and 
vagina.  Besides  these  symptoms,  which  are  constant,  there  are  others 
that  may  be  regarded  as  accidental.  If  stupor  and  delirium  appear 
during  the  stage  of  eruption,  these  symptoms  are  of  evil  augury.  If 
merely  due  to  habits  of  alcoholic  excess,  they  are  less  serious  than  if 
they  arise  spontaneously  under  an  increased  mobility  or  instability  of 


g56  ERUPTIVE  FEVERS. 

the  nerve-centers,  and  changes  in  the  composition  of  the  blood.  If 
there  be  maniacal  delirium,  with  suicidal  tendency,  the  result  is  usually 
death  about  the  beginning  of  the  stage  of  suppuration  (Jaccoud). 

8tage  of  Suppuration. — A  gradual  increase  in  the  number  of  pus- 
corpuscles  takes  place  from  the  beginning  of  the  vesicle,  and  the  con- 
tents of  the  pustule  are  entirely  purulent  by  the  ninth  day.  At  this 
time  each  pustule  enlarges,  and  assumes  a  hemispherical  form,  its  base 
broader  and  darker,  and  the  skin  around  it  becomes  swollen  and  tume- 
fied. The  broad  red  band  surrounding  each  pustule  is  known  as  the 
halo.  When  the  pustules  are  thickly  set,  the  swelling  is  universal  and 
the  redness  diffused.  Under  these  circumstances  the  head  is  much  swol- 
len, and  the  features  distorted,  so  that  the  individual  can  no  longer 
be  recognized.  This  distortion  is  the  more  conspicuous  about  the 
eyes  and  lips,  because  of  the  quantity  of  loose  connective  tissue,  per- 
mitting extensive  cedema  to  take  place.  Certain  parts  are  less  trou- 
bled by  the  eruption,  and  notably  Simon's  triangle,  which  is  the  favor- 
ite site  of  the  initial  rashes.  The  eruption  appears  on  the  body  and 
extremities  after  the  face,  and  consequently  is  maturing  in  these 
places  after  it  has  matured  on  the  face.  The  process  of  suppuration 
in  the  pustules  is  accompanied  by  a  symptomatic  fever.  A  chill,  or  a 
succession  of  chills,  mark  its  onset  in  some  subjects,  but  this  remark 
is  true  of  those  cases  only  in  which  the  appearance  of  the  eruption  was 
coincident  with  a  defervescence  of  the  fever,  or  at  least  with  a  consid- 
erable decline.  When  the  fever  has  persisted  from  the  beginning,  it  is 
increased  by  the  suppuration,  and  assumes  a  somewhat  different  type, 
becomes  remittent,  the  daily  variations  being  as  much  as  two  degrees. 
The  range  of  temperature  and  the  pulse-rate,  as  well  as  the  various 
kinds  of  disturbance  accompanying  the  fever,  are  greatly  influenced 
by  the  extent  of  the  suppuration.  The  temperature  will  rise  to 
104°,  105°,  or  106°  Fahr.,  and"  the  pulse  to  100,  120,  140,  or  higher. 
With  the  development  of  the  secondary  fever,  there  will  appear  all 
of  the  distressing  sensations  which  marked  the  initial  stage.  The 
headache  and  backache  again  become  severe,  the  whole  surface  of  the 
body  is  full  of  the  paiu  and  irritation  of  the  suppurating  sores,  there 
are  great  restlessness  and  wakefulness,  and  an  active  or  low-muttering 
delirium  comes  on.  Frequently  the  delirium  is  maniacal,  and  the  pa- 
tients difficult  to  restrain  :  they  jump  out  of  the  bed,  or  out  of  the 
window,  or  escape  into  the  streets.  In  children,  the  heat  and  burning 
of  the  face  are  so  great  that  they  will  scratch  the  parts,  covering  their 
hands  and  the  bedclothes  with  blood,  and  greatly  increasing  the  local 
inflammation. 

The  drying  of  the  pustules  begins  about  the  eleventh  day — 
rarely  earlier,  more  frequently  later — and  in  the  order  which  the 
eruption  followed.  The  drying  begins  before  the  disappearance  of 
the  fever  of  suppuration,  for,  when  the  face-pustules  have  completed 


VARIOLA.  g57 

their  evolution,  those  of  the  extremities  are  just  suppurating.  When 
the  desiccation  begins,  a  honey-like  exudation  is  poured  out  on  the  sur- 
face of  the  pustules,  which,  drying,  forms  an  adherent  coating.  The 
contents  of  the  j)ustules  also  desiccating,  a  brownish  scab  results.  Be- 
fore desiccation  has  taken  place  in  the  pustules  on  the  posterior  por- 
tions of  the  body,  the  matter  which  they  contain  is  pressed  out  on  the 
bedding  and  clothing  of  the  patient,  and,  decomposing,  a  peculiar 
odor  results,  which  to  many  persons  has  something  distinctive,  even 
diagnostic,  about  it.  Owing  to  the  thickness  and  hardness  of  the  epi- 
dermis, the  pustules  on  the  hands  and  feet  have  a  peculiar  form  and 
dry  earlier,  but  are  slower  to  separate.  As  the  pustules  dry,  the  red- 
ness and  swelling  of  the  skin  subside,  and  the  face  begins  to  assume 
something  of  its  natural  appearance,  albeit  somewhat  roughened,  red- 
dened, and  disfigured  by  the  disease.  Although  the  whole  body  is 
marked  by  cicatrices,  the  face  is  peculiarly  disfigured.  The  pustules 
involving  the  true  skin,  and  closely  placed,  extensive  losses  of  sub- 
stance may  occur,  especially  about  the  nose.  Ulcers  penetrating  the 
cornea,  protrusion  of  the  lens,  and  various  opacities,  result.  A  de- 
pressed and  radiated  cicatrix,  becoming  whiter  than  the  surrounding 
skin,  is  left  at  the  site  of  every  variola  pustule.  As  the  crusts  are  de- 
taching, there  is  often  an  intolerable  itching,  and  injury  is  done  by 
children  who  increase  the  area  of  inflammation  by  the  violence  of  the 
scratching.  Erysipelas  may  occur  and  furuncles  form  during  the 
jjrogress  of  the  dermatitis.  The  hair  usually  falls  out,  and  the  nails 
sometimes  drop  off. 

CONFLUENT  VARIOLA. 

The  description  above  given  applies  to  the  ordinaiy  cases  of  small- 
pox :  to  the  discrete,  the  corymbic,  and  the  coherent.  There  are  some 
peculiarities  of  other  forms  which  require  particular  consideration. 
The  approach  of  the  confluent  form  is  announced  by  the  greater  vio- 
lence of  the  initial  or  invasion  stage,  and  by  the  earlier  appearance  of 
the  eruption.  When  the  eruption  appears  it  spreads  over  the  body 
quickly,  and  indeed,  in  some  cases,  it  seems  to  be  on  the  face,  body, 
and  extremities  simultaneously.  At  once  the  papules  approximate, 
and  their  entire  formation  is  prevented  by  the  closeness  of  arrange- 
ment, so  that  large  numbers  coalescing  form  immense  vesicles  filled 
with  sero-pus.  While  the  face  and  features  are  hidden  under  huge 
bullae  of  pus,  the  pustules  on  the  rest  of  the  body  may  be  merely  cohe- 
rent. The  mucous  membrane  is  attacked  with  similar  violence  ;  the 
pustules  flow  together,  and  diphtheritic  exudations  spread  over  the 
fauces,  pharynx,  nares,  and  Eustachian  tubes.  The  tongue  is  greatly 
swollen,  and  protrudes  from  the  mouth.  Pustules  form  in  the  larynx, 
the  cartilages  are  invaded,  abscesses  develop,  and  oedema  of  the  glot- 
tis ensues.  The  parotid  and  sublingual  glands  swell  enormously.  The 
42 


658 


ERUPTIVE  FEVERS. 


cornea  is  opened  by  ulcerations,  and  staphyloma  results.  Erysipelas, 
phlegmonous  inflammation,  and  extensive  suppuration  may  occur  in 
those  parts  where  the  eruption  is  most  confluent,  and  even  gangrene 


Fig.  42.— Mild  Coufluent  Variola. 

results  in  extreme  cases.  The  systemic  state,  as  might  be  expected,  is 
quite  in  harmony  with  the  condition  of  the  skin  and  mucous  mem- 
brane. During  the  initial  or  invasion  stage,  the  temperature  reaches 
the  highest  point  human  temperature  ever  attains,  and  declines  but 
little,  sometimes  not  at  all,  and  always  slowly  when  the  eruption  ap- 
pears, continuing  at  104°  to  105°.  The  stomach  is  very  unsettled,  and 
vomiting  is  incessant,  scarcely  anything  being  retained.  The  urine  is 
scanty,  and  loaded  with  albumen.  If  the  patient  pass  through  the 
dangers  of  the  invasion  fever,  the  eruption  and  suppuration  stages, 
there  will  occur  in  the  stage  of  desiccation  extensive  losses  of  substance 
of  the  skin  of  the  face,  eyelids,  and  eyes,  and  of  the  scalp,  so  that  very 
great  deformity,  with  baldness,  will  result. 


HJEMORRHAGIO  VARIOLA. 

It  is  important  not  to  confound  haemorrhage  into  the  pustules,  or 
hcemorrhagic  variola,  with  purpura  variolosa,  which  is  the  hsemorrha- 
gic  diathesis  superadded  to  the  phenomena  of  variola.  Again,  the  hsem- 
orrhagic  rash  of  the  invasion  stage — ^merely  petechias — is  quite  distinct 
from  the  other  forms.  There  may  occur,  with  hsemon-hage  into  the 
vesicles,  extravasations  of  blood  into  the  adjacent  parts.  Only  a  por- 
tion of  the  eruption  may  be  affected  by  haemorrhage  into  the  pustules, 
or  it  may  be  general  over  the  body.  Blood  may  escape  into  the  pap- 
ules, or  not  until  the  stage  of  vesicles  is  reached,  but  the  most  usual 
condition  is  for  the  haemorrhage  to  occur  when  the  pustule  is  well  um- 
bilicated.  It  usually  takes  place  by  degrees,  beginning  on  the  lower 
extremities.  The  mucous  membranes  of  the  mouth  and  throat  are 
marked  by  extensive  ecchymoses,  and  diphtheritic  exudations  spread 
over  the  tonsils,  palate,  and  pharynx.     With  these  troubles  are  associ- 


VARIOLOID.  659 

ated  a  spongy  state  of  the  gums,  and  haemorrhages  from  the  nose, 
gums,  kidneys,  uterus,  and,  if  pregnancy  exists,  abortion  followed  by 
metrorrhagia.  The  general  condition  corresponds.  The  profound  al- 
teration in  the  composition  of  the  blood  manifest  under  these  circum- 
stances is  accompanied  by  very  great  prostration  of  the  vital  forces. 
But  there  are  great  differences  in  the  gravity  of  these  cases,  as  there 
are  in  the  extent  of  the  haemorrhagic  extravasations  ;  in  some  epidemics 
the  hemorrhagic  pustules  are  not  numerous,  and  the  general  condition 
not  unfavorable. 

VARIOLOID. 

Varioloid  is  a  form  of  variola  modified  by  previous  vaccination,  by 
a  former  attack  of  variola,  or  by  some  special  insusceptibility  to  the 
action  of  the  poison.  It  is,  however,  at  the  present  time,  almost 
wholly  the  influence  of  vaccination,  \Yhich  so  modifies  small-pox  as  to 
cause  it  to  take  the  mild  form  or  varioloid.  The  protective  influence 
of  vaccination,  or  of  an  attack  of  the  real  disease,  is  at  first  complete, 
but  the  longer  the  time  which  elapses  from  the  date  of  the  vaccination 
the  less  pi'otective  its  influence  ;  but  in  many  persons,  it  is  true,  this 
protection  continues  throughout  life.  It  is  a  peculiaiity  of  varioloid 
that  it  presents  numerous  points  of  departure  from  the  typical  course 
of  variola.  Thus  the  stage  of  invasion  may  be  one  or  two  days,  or 
three  or  four  ;  and  the  temjDerature  declines  very  abruptly  at  or  just 
after  the  appearance  of  the  eruption,  and  descends  to  or  below  nor- 
mal, and  it  remains  at  normal  until  the  stage  of  suppuration,  when  it 
assumes  a  transient  rise  of  not  more  than  one  or  two  days.  The  ini- 
tial or  invasion  rashes  of  the  erythematous  variety  belong  to  varioloid, 
and  not  to  variola,  and  the  more  decided  the  rash  the  less  abundant 
the  pustules.  Great  diversityand  difference,  as  compared  with  variola, 
exist  in  respect  to  the  manner  of  development  and  characteristics  of 
the  varioloid  eruption.  It  does  not  always  appear  first  on  the  face, 
but  on  the  chest,  abdomen,  or  extremities  ;  it  may  all  appear  simulta- 
neously over  the  body,  or  there  may  be  a  very  slow  eruption  of  the 
pustules.  While  the  structure  of  the  varioloid  pustule  does  not  differ 
from  that  of  variola  in  respect  to  development,  there  are  remarkable 
variations.  The  eruption,  although  it  may  apparently  be  as  complete 
as  variola,  never  goes  through  the  development  of  the  latter,  and  they 
abort  at  different  stages.  They  may  not  proceed  beyond  mere  pap- 
ules ;  they  may  develop  into  vesicles  and  then  dry  up  ;  they  may  be- 
come pustules,  surrounded  by  a  red  areola,  but  the  surrounding  skin  is 
not  swollen,  and  from  the  fifth  to  the  seventh  day  of  the  eruption  des- 
iccation occurs.  The  pustules  containing  a  sero-purulent  fiiiid  dry  up 
without  discharging,  and.  although  an  hypersemic  spot  remains  for  a 
short  time,  no  scar  is  left.  The  eruption  on  the  mucous  membrane  is 
usually  slight,  and  produces  but  little  disturbance. 


660  ERUPTIVE   FEVERS. 

Course,  Duration,  and  Termination. — The  discrete,  corymbic,  and 
coherent  forms  are  severe,  according  to  the  extent  and  number  of  the 
pustules,  and  pursue  a  course  of  great  uniformity.  The  most  formi- 
dable of  all  the  varieties  is  that  known  as  2:>urpura  variolosa — the 
hsemorrhagic  condition  or  diathesis  superadded  to  small-pox.  Death 
takes  place  in  this  form  before  the  characteristic  eruption  appears  or 
has  time  to  develop  ;  rarely  do  any  cases  live  beyond  the  sixth  day  of 
the  disease.  The  confluent  form,  although  largely  fatal,  is  not  inva- 
riably so.  The  termination  is  usually  by  pneumonia,  pleurisy,  or  peri- 
carditis, especially  the  last  two.  When  recovery  ensues,  the  conva- 
lescence is  tedious,  and  interrupted  by  various  complications,  especially 
abscesses  of  the  skin.  Very  often  the  termination  is  by  pyaemia.  The 
hsemorrhagic  pustular  form  is  characterized  by  great  intensity  of  the 
lumbar  pain,  and  by  remarkably  low  temperature,  which  may  persist 
throughout.  On  the  other  hand,  the  temperature  through  the  initial 
stage  and  subsequently  may  be  very  high.  This  form  is  more  pro- 
tracted than  purpura  variolosa,  and  almost  as  fatal.  The  mortality, 
however,  is  very  much  affected  by  the  number  of  pustules  into  which 
hsemorrhagic  extravasation  has  taken  place.  The  author  has  in  one 
epidemic  seen  at  least  four  cases  recover  out  of  six  of  the  hsemor- 
rhagic form,  but  the  pustules  of  the  face  were  chiefly  affected.  The 
course  of  small-pox  is  modified  by  various  complications.  Numerous 
points  of  inflammation  exist  throughout  the  brain  and  spinal  cord  in 
some  cases.  Serious  complications  on  the  part  of  the  eye  have  already 
been  mentioned,  consisting  of  ulcerations  of  the  cornea,  panophthal- 
mitis, haemorrhage  into  the  retina,  etc.  Chronic  otitis,  caries  of  the 
bones,  and  permanent  loss  of  hearing  result,  and  the  voice  is  hurt  by 
chronic  inflammation  of  the  larynx.  The  mortality  is  much  affected 
by  the  age  of  those  attacked  :  at  the  extremes  of  life,  notably  in  in- 
fancy, the  mortality  is  greater.  In  women,  owing  to  the  accidents 
growing  out  of  pregnancy,  the  mortality  is  greater  than  in  men.  Al- 
coholic excess  greatly  increases  the  danger.  All  those  circumstances 
lessening  the  vital  power  of  individuals  impair  the  power  of  resistance 
to  the  disease.  The  more  extensive  the  eruption,  as  has  been  stated, 
the  greater  the  danger.  Next  to  the  extent  of  the  skin  affection,  as  a 
measure  of  prognosis,  stands  the  pustulation  of  the  mucous  membrane. 
Diphtheritic  affections  of  the  throat  and  inflammation  of  the  larynx 
are  very  dangerous  complications.  The  duration  of  any  case  depends 
on  the  form,  extent  of  the  eruption,  the  complications,  etc.  An  or- 
dinary case  of  discrete  variola  will  not  run  its  course  under  five  or  six 
weeks. 

Treatment. — We  postpone  vaccination,  a  means  of  prophylaxis,  for 
separate  consideration.  We  possess  no  means  of  treatment  to  modify 
the  course  or  shorten  the  duration  of  small-pox.  All  specifics  may  be 
dismissed  with  the  assertion  that  they  have,  one  by  one,  proved  worth- 


VARIOLOID.  QQl 

less,  from  sarracenia  to  zylol.  The  treatment  is  therefore  symptomatic. 
Assertions  as  to  the  value  of  special  remedies,  or  plans  of  treatment, 
must  be  received  with  caution,  since  the  almost  univei'sal  practice  of 
vaccination  modifies  the  behavior  of  cases — effects  which  may  be 
readily  mistaken  for  the  influence  of  the  medication  employed.  When 
the  case  is  one  of  varioloid,  but  little  treatment  is  necessary.  In  the 
confluent  form,  treatment  is  as  little  important,  because  without  effect. 
During  the  stage  of  invasion,  the  high  temperature  and  the  cerebral 
disturbance  are  the  points  to  which  we  direct  attention.  To  allay  rest- 
lessness, delirium,  and  fever,  bromide  of  potassium  and  chloral  are  the 
most  eflicient  remedies.  If  the  headache  and  backache  are  very  in- 
tense, the  hypodermatic  injection  of  morphia  should  be  practiced  occa- 
sionally. The  bromide,  some  believe,  has  the  power  to  modify  the  erup- 
tion. When  the  secondary  fever  develops,  the  best  remedies  are  quinia 
in  five-grain  doses,  and  bromide  of  potassium  to  allay  cerebral  excite- 
ment. So  common  is  it  for  the  delirium  to  assume  a  maniacal  character 
that  the  utmost  care  is  necessary  to  prevent  accidents.  Chloral  is  not 
advised  to  be  given  at  this  period  by  the  stomach,  because  of  its  highly 
irritant  effect  on  the  fauces,  but  it  may  be  given  by  the  rectum.  Mor- 
phia, or  opium  in  some  form,  will  be  indispensable  to  relieve  the  pain- 
ful sensations  experienced  by  the  patient.  Depression  of  the  powers 
of  life  will  be  best  antagonized  by  the  free  use  of  carbonate  of  ammo- 
nia and  alcoholic  stimulants.  From  the  beginning,  proper  aliment  is 
necessary.  Milk,  eggs,  animal  broths,  oysters,  and  beef -juice,  should 
be  given  regularly  from  the  beginning,  every  three  hours.  Ice  is  al- 
ways grateful,  and  should  be  given  freely.  When  there  are  many 
pustules  in  the  mouth,  ice  should  be  held  in  the  mouth  as  much  as  pos- 
sible, and  ice  will  best  serve  to  allay  nausea.  If  there  is  much  vom- 
iting, the  hypodermatic  injection  of  morphia  is  the  most  eflficient 
remedy  to  arrest  it.  An  ice-bag  to  the  head  and  to  the  spine  will 
afford  much  relief  to  the  pain.  For  the  eruption  on  the  face  number- 
less expedients  have  been  resorted  to,  with  a  view  to  prevent  pitting. 
The  French  employ,  and,  as  they  think,  advantageously,  a  mercurial 
plaster.  It  is  probable  that  a  mask  of  some  unctuous  material,  thor- 
oughly applied  to  exclude  the  air,  has  a  beneficial  effect.  The  author 
has  used  with  apparent  advantage  the  glycerite  of  starch,  freely  ap- 
plied by  a  large  brush  several  times  a  day.  As  the  papules  are  about 
to  develop  into  vesicles,  the  tincture  of  iodine  should  be  painted  over 
them  thoroughly.  There  are  good  reports  from  this  practice.  Of  all 
the  local  applications,  there  is  nothing  so  serviceable,  according  to 
Curschmann,  as  water-dressings  to  the  face  and  hands.  Cold  com- 
presses are  kept  constantly  applied.  They  not  only  give  great  relief  to 
the  local  heat  and  burning,  but  diminish  the  swelling  of  the  skin.  If 
cold  is  not  pleasant,  warm  applications  may  be  used  instead.  For  the 
mouth-eruption,  solution  of  chlorate  of  potassa,  and,  if  there  is  much 


662  ERUPTIVE  FEVERS. 

fetor,  of  carbolic  acid,  is  useful.  Astringents  may  also  be  used  with 
advantage — such  as  fluid  extract  of  hydrastis,  of  eucalyptus,  and  sub- 
sulphate  of  iron.  When  the  crusts  are  falling  off,  warm  baths  assist 
in  detaching  them,  and  also  allay  the  troublesome  itching.  '  Inunctions 
of  lard,  of  suet,  of  vaseline,  after  the  warm  bath,  are  more  effective. 
All  the  excreta  of  the  patient  should  be  at  once  disinfected  by  carbolic 
acid,  sulphate  of  iron,  iodine,  etc.  The  air  of  the  apartment  should 
be  also  disinfected  by  the  vapor  of  iodine,  or  by  sulphurous  acid,  and 
the  halls  communicating  with  the  room  not  less  so.  All  articles  about 
the  patient  should  be  destroyed,  and  the  apartment  renewed  in  all  re- 
spects. 

VACCINIA  AND  VACCINATION. 

Vaccinia,  or  coio-pox,  is  a  natural  disease  occurring  in  the  cow  and 
horse,  and  possibly  some  other  animals.  It  is  a  vesicular  disease,  the 
eruption  limited  to  the  udder  and  teats,  and  occurs  sporadically  or  as 
an  epizootic.  It  seems  to  be  peculiar  to  milch-cows,  and  is  conveyed 
to  others  by  the  hands  of  milkers.  It  is  the  young  cows  who  are 
chiefly  affected,  and  the  course  of  it  is  essentially  the  same,  whether 
it  arises  spontaneously  or  is  propagated  by  inoculation.  In  the  natu- 
ral disease  the  period  of  incubation  is  usually  three  or  four  days,  but 
it  may  continue  from  five  to  eight.  The  udder  swells,  becomes  hot 
and  tender,  and  hard  papules,  the  size  of  a  pea,  appear  at  the  base  of 
or  on  the  teat.  When  the  disease  occurs  by  inoculation,  if  there  be 
a  crack  or  an  abrasion  of  the  skin,  a  papule  may  develop  as  early  as 
the  fifth  day,  but,  if  the  skin  be  unbroken,  not  until  the  eighth  or  ninth 
day.  In  three  or  four  days  after  their  first  appearance,  the  papule  has 
acquired  a  distinctly  vesicular  character,  and  a  central  pit  or  depres- 
sion is  then  to  be  seen.  In  four  days  more,  or  in  about  eight  days 
from  the  first  manifestation  of  the  papule,  the  formation  is  complete. 
They  vary  in  number  from  two  or  three  to  twenty  or  more,  and  their 
usual  size  is  about  that  of  a  dime.  Their  shape  is  somewhat  influenced 
by  their  position  :  on  the  teats  they  are  oval ;  at  the  base  of  the 
teat  round  ;  but  both,  forms  may  appear  on  the  udder,  and  on  the  teats 
they  may  be  coherent,  even  confluent.  Their  color  varies  somewhat, 
but  they  usually  have  a  shiny,  glistening,  metallic  luster  of  the  mar- 
gin, with  a  slate-colored  center.  They  are  surrounded  by  a  narrow 
areola,  pale-rose  or  damask-colored,  and  a  band  of  induration.  The 
color  and  tints  of  the  vesicle  and  of  the  areola  differ  somewhat,  ac- 
cording to  color  and  texture  of  the  skin.  When  the  development  is 
completed,  at  the  end  of  eleven  days,  the  lymph  is  abundant ;  the  cen- 
tral depression  disappears,  and  instead  there  is  a  conoidal  elevation. 
If  it  now  burst  or  is  opened,  a  quantity  of  a  straw-colored  or  amber- 
colored  lymph  flows  out  ;  but,  if  rupture  does  not  take  place,  the  lymph 
becomes  turbid  and  purulent,  and  by  the  fourteenth  day  a  crust  of  a 


VACCINATION.  g63 

brownish-black,  or  rather  mahogany,  color  has  formed,  the  areola  and 
the  marginal  band  of  induration  subsiding.  The  crusts  shrink,  dry, 
and  fall  off  about  the  twenty-third  day.  The  cicatrix  is  smooth,  oval, 
or  circular,  according  to  the  shape  of  the  vesicle,  and  whitish  in  color. 
When  the  vesicles  are  handled,  and  ruptured  as  in  milking,  there  will 
be  seen  large  black  scabs  adherent  at  some  points,  and  a  raw,  bleeding 
surface  at  others,  while  here  and  there  appears  a  properly  formed 
vesicle.  Examination  of  the  structure  of  the  vesicle  demonstrates  a 
number  of  partitions,  and  the  lymph  contained  in  the  spaces  formed 
by  them — an  arrangement  just  like  that  of  the  small-pox  vesicle.  The 
vaccine  disease  may  be  produced  by  inoculation  with  lymph  taken 
from  other  cows  suffering  with  the  disease  ;  with  the  lymph  of  horse- 
pox,  which  is  identical  with  the  cow-pox  ;  with  humanized  lymph,  or 
retro-vaccination  ;  and  by  the  matter  of  small-pox,  or  variolation. 
The  latter  process  has  given  origin  to  a  good  deal  of  controversy, 
owing  to  the  difficulty  of  inoculating  cows  with  the  matter  of  variola, 
but  it  has  been  accomplished  a  number  of  times,  the  results  being  in 
all  respects  the  same  as  ordinary  vaccinia — so  that  the  vaccine  dis- 
ease, as  Jenner  originally  maintained,  is  variola,  modified  by  transmis- 
sion through  the  system  of  the  cow. 

Vaccination. — It  would  be  a  misapplication  of  space  to  discuss  the 
value  of  vaccination  as  a  means  of  saving  men  from  the  greatest 
scourge  of  modern  times.  Shall  humanized,  Jennerian  lymph,  or  bovine 
virus  be  used  to  vaccinate  ?  The  following  facts  seem  conclusive  in 
favor  of  the  latter  :  The  carelessness  in  selecting  and  storing  the  hu- 
manized lymph  and  the  vast  numbers  of  transmissions  haA^e  impaired  the 
quality  of  the  product,  and,  although,  so  far  as  the  development  is  con- 
cerned, it  still  conforms  to  the  original  type,  its  protective  influence 
seems  less.  Again,  owing  to  carelessness  in  collecting  the  lymph,  the 
syphilitic  virus  has  been  inoculated  with  vaccine.  Much  prejudice  has 
been  excited  against  humanized  lymph,  and  hence  any  unavoidable  acci- 
dent occurring  from  its  use  would  be  referred  to  a  supposed  impurity. 
For  these  reasons  bovine  lymph  is  preferable.  The  objections  to  the 
latter  are,  that  it  is  less  certain,  and  that  its  action  is  violent,  a  good 
deal  of  constitutional  disturbance  being  caused  by  it.  The  lymph 
should  be  preserved  on  quills,  or  ivory  points  ;  and,  if  transported  a 
long  distance,  in  hermetically  sealed  tubes.  It  may  be  mixed  with 
glycerine  when  intended  to  be  kept  in  sealed  tubes  some  time.  When 
vaccination  is  performed  with  humanized  lymph,  it  is  preferable  to  use 
that  of  the  fresh  vesicle  on  the  seventh  or  eighth  day — or  "  arm-to- 
arm  vaccination,"  The  author  has  used  successfully  a  number  of 
times  lymph  that  had  been  transported  from  Germany,  The  lymph 
is  obtained  from  the  vesicle  of  the  seventh  or  eighth  day,  by  carrying 
an  incision  around  the  outer  border  of  the  vesicle  so  as  to  open  the 
several  chambers  of  which  it  is  composed,  care  being  taken  not  to  cut 


664  ERUPTIVE   FEVERS. 

or  injure  the  skin.  With  a  fine  pipette  the  lymph  may  now  be  with- 
drawn, and  mixed  with  two  parts  of  glycerine  and  two  of  distilled 
water,  and  preserved  in  capillary  tubes,  sealed  hermetically  with  seal- 
ing-wax. The  utmost  care  should  be  exercised  in  the  selection  of  the 
children  furnishing  the  lymph,  and  in  the  stock  from  which  the  virus 
is  derived.  In  practicing  vaccination,  the  skin  should  be  rapidly  and 
carefully  scraped  until  the  true  skin  is  reached,  and  it  is  ready  to  bleed. 
The  lymph  may  now  be  brushed  over  this  surface  with  a  camel's-hair 
brush.  Another  mode  is  to  make  three  or  four  horizontal  and  trans- 
verse cuts  about  four  lines  long,  or  to  insert  the  virus  on  the  point  of 
a  knife  by  a  single  puncture.  A  little  blood,  but  not  much  bleeding, 
should  be  caused  by  the  cuts  or  punctures.  Three  or  four  points 
should  be  selected  on  the  arm  or  leg  for  inserting  the  virus,  and  far 
enough  apart  so  that  the  areola — certainly  the  vesicles — can  not  coa- 
lesce. If  the  vaccination  "takes,"  a  papule  makes  its  appearance  on 
the  third  day  at  the  site  of  the  puncture  or  incision  ;  on  the  sixth  day 
a  vesicle  has  formed,  of  a  bluish- white  color,  having  a  raised  border 
and  a  central  depression  ;  on  the  eighth  day  it  is  fully  formed,  dis- 
tended with  lymph,  and  a  reddish  areola  surrounds  it,  which  widens 
to  two  inches  or  more,  and  there  is  very  considerable  induration  of 
the  skin  and  subcutaneous  areolar  tissue.  The  areola  begins  to  fade 
on  the  tenth  day,  and  the  contents  of  the  vesicle  become  turbid,  yel- 
lowish, and  thick,  begin  to  dry,  and  by  the  fourteenth  day  a  brown, 
mahogany  scab  or  crust  has  formed,  but  is  not  detached  until  about 
the  twenty-third  day.  A  genuine  crust  is  circular,  has  a  rounded  and 
elevated  border,  a  central  cup  or  depression,  and  it  has  a  dark-brown 
or  mahogany  color.  The  cicatrix  left  is  circular,  depressed,  radiated 
and  foveated,  and  is  usually  permanent,  becoming  after  a  time  paler 
and  whiter  than  the  surrounding  integument.  More  or  less  constitu- 
tional disturbance  attends  vaccination  in  children  with  a  mobile  ner- 
vous system  :  fever,  when  the  vesicle  is  at  its  maximum  ;  restlessness  at 
night,  etc.  An  eruption  of  roseola  may  take  place,  or  a  papular  erup- 
tion— a  lichen — may  appear.  In  scrofulous  children  an  eczema  maybe 
produced  from  the  irritation  caused  by  the  development  of  the  vesicle, 
or  an  otorrhoea  may  follow,  etc.  The  lymph  is  usually  held  respon- 
sible for  such  accidents,  but  in  strumous  subjects  the  slightest  wound 
may  be  followed  by  the  same  cutaneous  troubles.  As  the  protection 
is  for  a  period  which  varies  in  different  individuals,  and,  although  for 
the  whole  life  in  most  subjects  when  properly  done,  expires  in  others 
in  a  few  years,  it  is  necessary  to  repeat  it  at  certain  periods.  Re- 
vaccination,  practiced  now  in  the  great  Continental  armies,  has  had  a 
remarkable  influence  in  checking  small-pox,  and,  as  these  statistics  are 
on  an  enormous  scale  and  are  accurate,  the  lesson  taught  us  by  them 
ought  to  be  heeded.  When  there  is  some  special  exjjosure  to  conta- 
gion, vaccination  should  be  practiced  ;  but  as  a  rule,  and  entirely  irre- 


VARICELLA.  6^5 

spective  of  contagion,  revaccination  should  be  done  about  the  fifth 
year,  after  the  second  dentition,  and  at  puberty.  If  properly  done  at 
these  times,  further  vaccination  will  be  unnecessary. 


VARICELLA. 

Definition. —  Varicella  is  a  febrile  affection,  characterized  by  the 
appeai'ance  of  a  vesicular  eruption  with  the  first  elevation  of  tempera- 
ture, the  vesicles  drying  up  and  falling  off  in  from  three  to  five  days, 
the  elevation  of  the  temperature  ceasing  at  the  same  time.  It  is  known 
in  common  language  as  chicken-pox. 

Causes. — That  it  is  an  independent,  specific  affection,  propagated 
by  some  peculiar  poison,  is  now  generally  admitted.  Its  identity  with 
varioloid  has  been  and  is  still  maintained  by  some  authorities,  but  on 
insufficient  grounds.  It  is  a  disease  of  childhood,  and  rarely  attacks 
any  one  above  ten  years  of  age.  It  occurs  both  sporadically  and  as 
an  epidemic.  The  mode  of  communication  is  unknown,  and,  although 
contagious,  is  not  actively  so. 

Pathological  Anatomy. — The  eruption  is  both  discrete  and  corymbic 
— vesicles  occur  singly  and  in  groups,  and  they  vary  in  size  from  a 
pin's-head  to  a  pea,  reaching  sometimes  the  size  of  a  silver  dime.  They 
may  be  few  in  number,  from  ten  to  thirty,  or  they  may  be  numerous, 
reaching  one  thousand.  They  consist  of  perfectly  transparent  vesicles, 
containing  a  clear,  watery,  sometimes  yellowish  fluid,  faintly  alkaline 
in  reaction.  They  form  on  a  spot  which  is  slightly  hypertemic,  and 
are  surrounded  by  a  faint  areola,  which  is,  however,  often  absent. 
They  continue  at  their  maximum  not  longer  than  a  day,  when  they 
begin  to  be  flaccid,  dry  in  the  center,  and  form  a  small,  yellow,  or 
brownish  crust,  which  falls  off  in  two  or  three  days,  leaving  a  faint 
reddish  spot  which  disappears  entirely  in  a  few  days,  and  sometimes  a 
cicatrix,  which,  however,  is  shallow  and  very  rarely  permanent. 

Symptoms. — The  eruption  of  the  vesicles  is  the  first  symptom  to  at- 
tract attention,  for  there  is  no  fever  of  invasion,  and  no  prodromes  that 
have  been  accurately  studied.  With  the  appearance  of  the  eruption, 
a  rise  of  temperature  begins,  but  it  is  not  often  the  case  that  the  tem- 
perature rises  high  enough  to  be  a  subject  for  solicitude,  the  thermom- 
eter marking  one,  two,  rarely  three  degrees  above  normal.  The  erup- 
tion first  appears  on  the  trunk,  and  then  extends  quickly  to  the  ex- 
tremities. The  hairy  scalp  usually  contains  a  number.  At  first  a  spot 
of  roseola  appears,  and  on  this  is  quickly  projected  a  vesicle.  Between 
the  first  crop  of  vesicles,  on  the  next  day,  are  seen  a  number  of  roseola- 
spots,  and  on  these  other  vesicles  make  their  appearance.  But  few 
appear  on  the  face,  and  those  chiefly  on  the  forehead.  The  disease 
reaches  its  maximum  on  the  second  day  and  then  declines,  the  fever 
disappearing,  the  vesicles  drying  up  and  dropping  off.     The  vesicles 


QQQ  ERUPTIVE  FEVERS. 

also  appear  on  the  mucous  membrane  of  the  mouth  and  on  the  geni- 
tals. The  general  symptoms  are  trivial.  With  the  fever  there  are 
thirst,  anorexia,  and  constipation.  Sleep  is  disturbed,  and  much  itch- 
ing is  complained  of,  especially  in  the  scalp.  The  eyes  are  apt  to  be 
irritable,  and  it  occasionally  happens  that  vesicles  aj^pear  on  the  con- 
junctiva, but  the  popular  notion  that  chicken-pox  is  hurtful  to  the  eyes 
is  unfounded. 

Treatment. — There  is  nothing  to  be  done  but  await  the  termination 
of  the  case  by  the  natural  mode. 

MEASLES— RUBEOLA. 

Definition. — Ifeasles  is  an  eruptive  fever,  with  catarrhal  symptoms 
referable  to  the  broncho-pulmonary  mucous  membrane,  self -limited, 
and  terminating  in  about  two  weeks. 

Causes. — According  to  Lombard,  measles  appears  in  all  j)arts  of 
the  globe,  but  is  much  less  severe  in  the  tropics  and  in  extreme  north- 
ern countries.  It  is  a  contagious  disease,  which  may  be  communi- 
cated not  only  by  immediate  communication  with  the  sick,  but  the 
morbific  principle  adheres  to  fomites,  to  articles  of  clothing,  etc.,  by 
which  it  may  be  conveyed  long  distances,  and  by  means  of  the  healthy. 
It  has  been  communicated  by  inoculation.  The  nasal  mucus  seems 
rich  in  the  morbific  principle.  Measles  prevails  widely  as  an  epidemic, 
and  it  occurs  also  in  the  sporadic  form.  Susceptibility  to  it  is  not  the 
same  in  all  individuals.  Infants  at  the  breast  are  not  liable.  The  two 
sexes  are  affected  with  equal  frequency.  During  an  epidemic,  not  all 
exposed  to  the  epidemic  influence  have  the  disease.  One  attack,  as  a 
rule,  gives  exemption  from  future  attacks  ;  but  to  this  dictum  there 
are  numerous  exceptions.  It  is  a  disease  of  childhood  esj^ecially, 
although  infrequent  in  infants  at  the  breast,  and  a  few  cases  have 
been  reported  in  which  measles  existed  at  birth.  The  atmospherical 
conditions  which  favor  the  production  of  bronchial  attacks  promote 
the  epidemics  of  measles,  which  are  therefore  more  numerous  and 
severe  in  the  fall,  winter,  and  spring.  The  period  of  the  disease  when 
the  contagion  is  most  active  is  probably  when  the  eruption  is  at  its 
maximum  ;  but  the  contagious  principle  is  present  from  the  beginning 
to  the  end  of  symptoms. 

Pathological  Anatomy. — The  eruption  of  measles  is  in  dark-red, 
sometimes  rose-colored,  spots,  sharply  defined,  about  the  size  of  a  pin- 
head  to  three  pin-heads,  disappearing  on  pressure,  and  immediately 
recurring  when  the  pressure  is  removed.  These  spots  have  a  lenticular 
shape,  are  usually  discrete,  and  separated  by  tracts  of  normal  skin,  but 
may  be  coherent,  forming  an  extended  area  of  diffused  redness,  with 
punctations  of  deeper  red,  while  the  intervening  skin  is  untouched.  The 
spots  are  slightly  raised  above  the  general  surface,  and  each  spot  maybe 


MEASLES.  667 

surmounted  with  a  very  minute  papule  ;  but  this  papule  is  not  always 
present.  The  eruption  of  measles,  with  or  without  a  papule,  makes 
the  skin  rough.  The  spots  appear  on  all  parts  of  the  body,  but  more 
on  the  face  and  trunk  than  on  the  extremities  ;  and  they  are  more  apt 
to  cohere  on  the  face  and  to  be  more  abundant  in  this  situation  also, 
and  of  a  brighter  color.  The  exanthem  appears  first  on  the  face,  then 
on  the  neck,  throat,  upper  part  of  the  chest,  and  abdomen.  It  may 
develop  fully  on  the  face  and  continue  there  unchanged  for  a  day  or 
two  before  appearing  elsewhere.  The  duration  of  the  eruption  at  its 
maximum  of  development  is  not  more  than  a  half -day  or  a  day,  when 
retrocession  goes  on  rapidly,  beginning  usually  in  the  evening  or  at 
night,  where  the  exanthem  first  came  out,  and  in  twenty-four  hours 
the  skin  is  pale.  As  the  retrocession  is  going  on,  an  exacerbation  may 
occur,  when  the  spots  will  appear  again,  almost  to  their  original  devel- 
opment ;  but  this  is  exceptional,  and,  if  it  happen,  fading  will  soon  (in 
a  few  hours)  go  on  again.  Some  color  remains  for  a  few  days  at  the 
site  of  the  eruption — a  brownish  or  yellowish  stain — and,  in  the  case 
of  haemorrhagic  extravasation,  which  may  take  place  in  the  skin  during 
the  height  of  the  eruption,  the  petechial  spots  pass  through  the  ordi- 
nary changes.  More  or  less  exfoliation  takes  place  in  the  form  of 
furfuraceous  scales,  and  only  from  the  spots  ;  large  patches,  like  those 
of  scarlet  fever,  are  not  known  in  measles.  The  mucous  membrane  is 
affected,  as  well  as  the  skin,  but  in  a  different  form.  An  intense 
hyperemia  of  the  nares,  pharynx,  palate,  larynx,  and  conjunctiva, 
comes  on  with  the  initial  stage.  To  this  state  of  hyperemia  are 
superadded  dark-red  spots,  appearing  with  and  corresponding  to  the 
skin  exanthem,  although  not  resembling  it  very  closely.  Minute 
papules  are  also  seen  to  develop,  but  not  in  connection  with  the  red 
spots.  Retrocession  of  the  mucous-membrane  exanthem  occurs  a  lit- 
tle earlier  than  that  on  the  skin.  In  the  measles  of  the  war  of  the 
rebellion,  intestinal  changes  were  constantly  observed,  and  consisted 
of  enlargement  of  the  solitary  glands,  more  or  less  thickening  of  the 
patches  of  Peyer,  and  swelling  of  the  mesenteric  glands.  The  spleen 
was  always  enlarged  by  increase  of  the  splenic  pulp,  and  the  kidneys 
were  intensely  hypersemic,  the  urine  containing  albumen.  The  blood 
was  thin,  the  fibrin  slight  in  quantity  and  feebly  coagulable,  the  red 
corpuscles  diminished  and  the  white  in  excess. 

Sjnnptoms— Invasion  Stage. — The  onset  of  the  disease  is  announced 
by  a  feeling  of  weariness,  muscular  Soreness,  headache  and  backache, 
and  a  succession  of  irregular  chills,  the  temperature  then  rising  to 
100°  or  101°  Fahr.  These  symptoms,  which  mark  the  beginning  of 
the  prodromal  or  invasion  stage,  succeed  to  the  incubation  stage. 
From  the  period  of  exposure  to  the  appearance  of  the  eruption  there 
are  fourteen  days,  according  to  the  most  accurate  observations.  As 
four  of  these  are  occupied  by  the  invasion  stage,  the  pei-iod  of  incuba- 


66.8 


ERUPTIVE  FEVERS. 


tion  must  be  fixed  at  ten  days,  or  from  nine  to  eleven  days.  During 
the  incubation  period  there  is  no  recognizable  departure  from  the  nor- 
mal, and  the  symptoms  of  the  invasion  stage  come  on  rather  abruptly. 
Together  mth  the  symptoms  above  mentioned  as  indicating  the  ap- 
proach of  measles,  there  is  an  intense  nasal,  pharyngeal,  and  laryngeal 


102' 


100' 


98" 


96°i   Mill 


7 


m 


8 


N 


n 


10 


s^sM 


II 


12 


FiGr.  48. — Uncomplicated  Measles. 

catarrh,  which  usually  appears  on  the  first,  but  may  be  postponed  to 
the  second  day.  The  fever  rises  to  102°,  where  it  usually  remains  for 
the  first  day  or  two,  and  its  intensity  furnishes  a  measure  of  the 
severity  of  the  attack.  On  the  second  or  third  day — usually  the  sec- 
ond— a  remarkable  remission  takes  place,  the  temperature  descending 
to  normal  or  nearly  so.  On  the  evening  of  the  third  or  the  morning 
of  the  fourth  day  the  fever  rises  again  to  the  original  height.  'With 
this  decline  in  temperature,  there  ensues  an  improvement  in  the  gen- 
eral condition  :  the  headache  ceases  and  the  general  discomfort  less- 
ens ;  but  the  catarrhal  condition  does  not  moderate  ;  the  nasal  mu- 
cous membrane  swells  ;  breathing  through  the  nose  is  difiicult ;  there 
are  frequent  paroxysms  of  sneezing,  and  presently  an  abundant  secre- 
tion of  mucus  is  poured  out  from  the  membrane.  The  eyes  are  swol- 
len, the  conjunctivae  injected,  the  lids  cedematous,  and  hot,  scalding 
tears  flow  over  the  cheeks.  During  this  time  epistaxis  is  frequent, 
especially  in  children.  By  the  third  day  the  catarrh  reaches  the 
larynx,  and  then  the  voice  becomes  hoarse  and  husky,  the  cough 
harsh,  resounding,  metallic,  stridulous.  At  first  there  is  no  expectora- 
tion, and  only  sibilant  rales,  but  more  or  less  prsecordial  oppression 
and  anxiety  are  felt. 

Eruption  Stage. — The  characteristic  eruj)tion  of  measles  makes  its 
appearance  on  the  fourth  day,  and  is  rarely  postponed  to  the  fifth.  In 
the  milder  cases  the  eruj^tion  appears  on  the  morning  of  the  fourth 
day ;  in  the  severer  cases,  in  the  after  part  of  the  same  day  ;  and  it  is 
seen  first  on  the  face,  forehead,  chin,  and  cheeks,  spreading  thence 
often,  after  an  interval,  over  the  body  and  extremities.  The  fever 
attains  its  maximum  on  the  appearance  of  the  eruption,  or  on  the  fifth 


MEASLES.  669 

day,  or  there  may  be  remissions — the  maximum  on  the  evening  of  the 
fourth,  and  a  remission  on  the  morning  of  the  fifth.  The  color  of  the 
spots  is  deepest  when  the  temperature  is  highest.  The  condition  of 
the  mucous  membrane  continues  the  same,  but  the  cough  soon  be- 
comes easier  because  of  the  abundant  secretion  of  mucus,  soon  assum- 
ing a  muco-purulent  character.  Complications  may  arise  at  this  point ; 
considerable  bronchitis  may  develop  ;  diarrhoea  comes  on  ;  albumen 
(usually  a  trace)  appears  in  the  urine.  These  symptoms  were  usual 
and  constant  at  this  period  of  army  measles.  About  the  seventh  to  the 
ninth  day  the  eruption  on  the  face  begins  to  pale,  and  the  turgescence 
and  redness  of  the  visage  lessen.  With  the  retrocession  of  the  erup- 
tion the  temperature  declines  somewhat,  and  the  normal  is  reached  in 
a  day  or  two.  The  defervescence  may  be  sudden  and  without  inter- 
ruption, the  normal  being  reached  in  a  day,  or  it  may  be  gradual  and 
varied  by  exacerbations  and  remissions.  The  slight  desquamation  that 
takes  place  is  soon  completed.  Convalescence  may  be  retarded  by  an 
irritable  state  of  the  intestinal  canal. 

Course,  Complications,  and  Anomalies. — The  course  and  behavior  of 
measles  are  much  affected  by  the  character  of  the  epidemic  influence, 
by  the  susceptibility  of  the  individual  and  the  hygienic  surroundings. 
As  it  prevails  in  armies,  measles  comes  to  be  a  formidable  disease, 
comparable  only  to  typhoid  ;  sporadically,  under  favorable  conditions, 
it  is  of  very  minor  importance.  In  some  epidemics  many  of  the  cases 
are  very  mild — cases  of  measles  without  the  catarrh ;  other  cases,  in 
which  the  catarrh  and  other  symptoms  are  present,  but  the  eru2:)tion  is 
absent.  On  the  other  hand,  some  epidemics  are  characterized  by  the 
severity  of  the  cases.  Thus,  in  some  epidemics,  the  haemorrhagic  diath- 
esis complicates  miany  cases,  and  they  present  the  usual  phenomena 
significant  of  jjrofound  alteration  of  the  blood.  Before  the  eruption 
makes  its  appearance,  or  subsequently,  haemorrhages  take  place  in  the 
skin  from  all  the  mucous  surfaces,  and  into  the  parenchyma  of  organs. 
Profound  adynamia  sets  in  ;  the  pulse  is  rapid  and  weak  ;  the  lungs 
are  disabled  by  an  extensive  broncho-pneumonia  ;  the  abdomen  is 
tympanitic,  and  profuse  watery  and  offensive  stools  are  discharged  ; 
the  tongue  is  dry,  the  teeth  covered  with  sordes  ;  and  low-muttering 
delirium  ushers  in  death.  A  fatal  result  is  not  invariable,  although 
usual  in  the  haemorrhagic  form.  The  eruption  may  be  absent  in  the 
mildest  cases  ;  it  may  pursue  an  irregular  course,  appear  on  the  trunk 
before  the  face,  remain  on  a  very  short  time,  or  continue  much  longer 
than  normal.  Very  high  fever  during  the  invasion  stage,  or  great 
prostration,  is  significant  of  a  severe  case.  The  temperature  fur- 
nishes the  most  certain  guide  to  the  actual  state.  Sometimes  the 
eruption  returns,  the  fever  lights  up,  and  all  the  phenomena  of  the 
disease  are  repeated.  Various  cutaneous  eruptions  may  appear  with 
the  normal  exanthem  :  as  miliary  vesicles,  pustules,  bullae,  and  urti- 


670 


ERUPTIVE  FEVERS. 


caria.  Serious  complications  on  the  part  of  the  eye  must  be  noted — 
such  as  conjunctivitis,  keratitis,  iritis,  etc.  The  larynx  is  the  seat  of 
ulcerations  and  erosions.  Inflammation  of  the  middle  ear,  succeeded 
by  chronic  otorrhoea,  also  takes  place.  But  the  most  frequent  and 
serious  complications  are  capillary  bronchitis,  pneumonia,  catarrhal 
pneumonia,  etc.  In  some  epidemics  these  complications  are  more 
numerous  than  in  others,  but  the  constitutional  state  and  the  hygienic 
surroundings  are  chiefly  responsible.  Capillary  bronchitis  and  pneu- 
monia occur  during  and  after  the  stage  of  eruption.  In  strumous  sub- 
jects catarrhal  pneumonia  may  undergo  the  transformation  into  case- 
ous, which  is  the  explanation  of  the  frequent  occurrence  of  phthisis 
after  measles.  The  constant  association  of  enlarged  follicles  and  intu- 
mescence of  Peyer's  patches  in  measles  with  the  other  morbid  altera- 


Dai'  6    7     8    9    10    11    12    13   14    15   16    i7    18    19  20  21  22  23 

lOfi-                                                 1 

'0*"                   -^                   4                   -r                                                                          r*       4       -?>r- 

^  ^    A         f     9     /\                                  h     \      \ 

\     l^<,     V      h     '\    A                                              u              \             I 

/    'A   /     A  '/  I  /\    A                      /  ¥*     f 

\/   I  / W     ri  /  V  1    /i                   .if 

1'^''       ^'  \y     /     /     /       I  J                     A  /          /     ' 

V    \/     /     /        I,         «              J           \     \ 

1        y    1^   if        \i    I     A          /^                \ 

1              1/    \/         V    \    /          J               / 

"    V               \  ,    V^v^               V     \  . 

1(10°         1               '     "                W    ^'^^                 *       \A   , 

t 

Jt_4^ 

98°                                                                                                 .- 

1 

96°                        zl:                           ^ 

Fig.  44.— Measles  complicated  -witli  Catarrhal  Pneumonia. 

tions  characteristic  of  the  disease,  observed  by  the  author  in  numer- 
ous autopsies,  seems  to  justify  his  conviction  that  the  former  are 
really  incident  to  the  disease.  An  obstinate  diarrhoea  and  dysentery 
(ileo-colitis)  may  occur  at  any  point  in  the  disease,  but  are  especially 
troublesome  from  the  period  of  retrocession  of  the  eruption.  Death 
is  often  due  to  this  complication,  or  the  convalescence  is  made  very 
tedious.  Simple  uncomplicated  cases  of  measles  are  free  from  danger. 
The  indications  that  bode  danger  to  life  are  an  excessively  high  fever 
during  the  period  of  invasion  ;  sparseness  and  dimness  of  the  eruption 
while  the  general  state  is  bad  ;  confluence  of  the  eruption  and  hsemor- 
rhagic  diathesis  ;  anomalies  in  the  development  of  the  eruption,  the 
other  symptoms  being  unfavorable ;  capillary  bronchitis,  broncho- 
pneumonia, etc.  ;  intestinal  disorders,  severe  ileo-colitis,  etc.  ;  and 
cerebral  complications. 

Treatment. — Mild  cases  require  confinement  in-doors  or  to  bed,  on  a 
regulated  diet,  and  a  little  paregoric  to  quiet  a  troublesome  cough.    If 


MEASLES.  671 

the  temperature  is  high  during  the  initial  stage,  and  the  cough  trouble- 
some, a  combination  of  aconite,  ipecac,  and  opium  is  highly  service- 
able (tinct.  aconiti  rad.,  3  j,  ext.  ipecac,  fi  3  ij,  tine,  opii  deod.,  3  iij. 
M.  Sig.  Six  drops  every  hour  or  two).  If  the  aconite  fail  to  reduce 
the  temperature  (the  remission  occurring  during  the  invasion  stage 
should  not  be  overlooked),  a  tea-  to  a  tablespoonful  of  infusion  of  digi- 
talis may  be  given  three  or  four  times  a  day  in  addition.  During 
the  time  of  eruption,  if  the  temperature  is  high,  the  skin  should  be 
rubbed  every  four  hours  with  lard,  or  suet,  or  vaseline,  or  cacao-butter  ; 
and,  if  the  fever  is  moderate,  three  times  a  day.  If  the  bowels  are 
confined,  a  simple  saline  laxative  ought  to  be  given.  Free  action  of 
the  kidneys  can  be  maintained  by  cooling  drinks.  The  temperature 
of  the  apartment  should  be  about  70°,  and,  while  it  is  well  ventilated, 
all  draughts  must  be  excluded.  The  popular  notion  that  measles  re- 
quires a  close  room  and  blankets  is  a  very  pernicious  one.  The  other 
extreme  is  equally  dangerous.  Such  are  the  simple  measures  required 
in  uncomplicated  measles.  When  very  high  fever  obtains  thi-ough  the 
prodromal  stage,  or  subsequently,  the  antipyretic  treatment  most 
effective  is  the  wet  pack.  The  bed  is  protected  by  a  rubber  cloth,  and 
over  this  is  placed  folded  flannel  of  sufficient  dimensions  ;  a  sheet 
wrung  out  in  water,  each  time  beginning  at  95°  and  gradually  cooled 
to  80°,  is  laid  on  the  flannel ;  the  patient  is  placed  on  the  sheet  and 
quickly  wrapped  up.  This  operation  is  repeated  every  half -hour  until 
the  heat  is  reduced.  Besides  the  diminution  of  fever-heat,  the  wet 
pack  develops  the  eruption,  and  exercises  a  most  favorable  influence 
on  the  course  of  capillary  bronchitis  and  pneumonia,  whence  it  is  to  be 
especially  commended  when  the  high  temperature  is  the  result  of  the 
pulmonary  complication.  Quite  irrespective  of  the  temperature,  local 
wet  packs  are  of  very  considerable  importance  in  the  treatment  of 
measles.  The  vapor  of  water  allays  the  nasal  stuffing  and  the  sneezing, 
and  tepid-water  compresses  best  relieve  the  irritation  of  the  conjunc- 
tiva. Tonsillitis  and  laryngitis  are  much  benefited  by  enveloping  the 
neck  in  a  tepid  pack,  and  frequently  renewing  it.  Packs  and  com- 
presses are  especially  efficacious  in  the  treatment  of  inflammatory  affec- 
tions of  the  chest  and  abdominal  organs.  If  baths  cannot  be  utilized 
to  reduce  temperature,  quinia  comes  next  in  point  of  efficiency.  To 
effect  any  decided  reduction  of  temperature,  large  doses  must  be  given 
— from  five  to  twenty  grains  every  four  hours — until  a  change  occurs. 
Digitalis  may  be  advantageously  combined  with  quinia  if  the  stomach 
does  not  prove  rebellious.  In  the  hsemorrhagic  form,  quinia,  the  min- 
eral acids,  tincture  of  ferri  chloridi,  turpentine,  etc.,  are  especially 
indicated.  The  most  important,  as  it  is  the  most  frequent  complica- 
tion, requiring  careful  therapeutical  handling,  is  capillary  bronchitis, 
with  atelectasis,  broncho  -  pneumonia,  etc.  The  salts  of  ammonia, 
especially  the  carbonate  and  iodide,  are  of  immense  value  in  this  state. 


672  ERUPTIVE  FEVERS. 

The  plasticity  and  adhesiveness  of  the  exudation  are  lessened  by  them, 
and  thus  the  access  of  air  to  the  alveoli  is  favored.  They  may  be  ad- 
ministered in  an  emulsion  together,  or  the  carbonate  may  be  dissolved 
in  solution  of  the  acetate.  The  vapor  of  water  is  an  important  adjunct 
to  the  other  means  for  lessening  the  obstruction  of  the  tubes,  and  hence 
steam  should  be  freely  disengaged  in  the  apartment.  The  volatile 
expectorants  are  very  serviceable,  in  that  they  diffuse  out  of  the  blood 
through  the  lungs,  and  thus  act  locally  on  the  affected  surface.  The 
most  efficient  of  these  are  eucalyptol  and  turpentine,  especially  the  lat- 
ter, which  is  particularly  indicated  when  the  capillary  circulation  is 
feeble,  the  eruption  pale,  and  the  skin  bluish.  If  the  means  resorted 
to  fail  to  remove  the  obstruction  in  the  capillary  tubes,  emetics  become 
necessary.  The  subsulphate  of  mercury,  alum,  or  sulphate  of  zinc,  may 
be  employed  for  this  purpose — their  repetition  being  determined  by 
the  results,  Tartar  emetic,  which  is  often  used,  is  greatly  too  depress- 
ing, and  is  dangerous.  Apomorphia  may  also  be  given,  but  the  re- 
markable effect  which  it  now  and  then  has  on  the  heart  is  a  serious 
objection  to  its  employment.  In  the  intestinal  complication  the  author 
has  had  the  best  results  from  the  conjoined  administration  of  Fowler's 
arsenic  (two  drops)  and  opium  (deodorized  tincture,  five  to  ten  drops) 
every  four  hours,  and  from  sulphate  of  copper  and  sulphate  of  morphia 
GV  *o  fV  grain  of  the  former,  and  xs"  ^<^  "i"  g^^ain  of  the  latter,  for  adults, 
three  times  a  day).  Very  careful  alimentation  should  be  du'ected  from 
the  beginning,  and  should  consist  largely  of  milk,  especially  if  there  is 
a  trace  of  albumen  in  the  urine. 


ROSBOLA— ROETHELN  (GERMAN  MEASLES). 

Definition. — By  the  modern  German  authors  the  term  rubeola  is 
restricted  to  this  disease,  which  is  usually  called  roseola  in  this  coun- 
try. Following  the  course  usually  taken  by  American  authorities, 
the  term  rubeola  has  been  applied  to  true  measles.  Roseola  is  a  self- 
limited  eruptive  disease,  pursuing  a  course  similar  to  measles. 

Causes. — This  is  a  disease  of  early  life,  appearing  equally  in  the 
two  sexes,  and  propagated  by  infection.  It  does  occur  in  adults,  but 
less  frequently.  One  attack  procures  an  exemption  against  future  at- 
tacks, but  this  is  not  an  absolute  rule.  That  a  peculiar  materies  morbi, 
virus,  or  germ  exists  is  probable,  but  thus  far  it  has  not  been  isolated. 

Pathogeny  and  Symptoms. — The  eruption  consists  of  rose-colored 
spots,  the  size  of  a  pin-head  up  to  three  or  four  pin-heads,  well  defined 
and  somewhat  elevated,  so  that,  when  a  number  are  placed  near  each 
other,  the  skin  is  distinctly  rough.  An  hypersemia  of  the  papilla  takes 
place,  and  of  the  adjacent  cells  of  the  derma  above,  and  the  redness  in 
spots  and  the  elevation  of  the  hypersemic  patch  give  the  impression 
of  roughness.     The  spots  have  a  round  or  somewhat  oval  shape,  dis- 


SCARLATINA.  673 

appear  on  pressure,  to  return  immediately  when  the  pressure  is  with- 
draAvn.  The  spots  vary  a  good  deal  in  size,  and  are  rarely  confluent  or 
coherent.  On  the  face,  where  they  are  most  abundant,  they  do  not 
flow  together.  They  are  nearly  as  abundant  on  the  neck,  chest,  and 
abdomen.  The  eruption  is  quite  abundant  on  the  scalp,  and  extends 
freely  over  the  extremities.  The  maximum  development  of  the  spots 
is  about  half  a  day,  but  the  whole  duration  of  their  existence  is  from 
two  to  four  days.  A  very  slight  discoloration  remains  for  a  day  or 
two  at  the  site  of  the  spots,  and  very  little,  if  any,  desquamation  takes 
place.  From  the  period  of  exposure  until  the  onset  of  the  disease 
there  are  from  ten  to  fourteen  days.  No  symptoms  occur  until  the 
eruption  appears  ;  in  other  words,  there  is  no  prodromal  stage,  or  inva- 
sion, or  initial  stage.  There  is  no  fever  in  a  majority  of  the  cases. 
The  eruption  appears  first  on  the  face  and  spreads  thence  regularly 
over  the  scalp,  body,  and  extremities,  in  about  the  same  order  as 
measles.  A  light  grade  of  catarrh  comes  on  with  or  immediately  suc- 
ceeds to  the  eruption,  and  there  are  redness,  stufling  of  the  nose,  sneez- 
ing, conjunctivitis,  photophobia,  etc.,  but  all  of  these  symptoms  are 
much  less  severe  than  the  corresponding  symptoms  in  measles.  More 
or  less  diffused  redness,  with  punctations  of  deeper  color,  is  observed 
in  the  mucous  membrane  of  the  fauces,  pharynx,  and  larynx.  Disor- 
ders of  the  intestinal  canal  or  of  the  kidneys  do  not  occur.  In  general 
the  symptoms  are  so  slight  that  children  object  to  any  restraint  or 
confinement.  Even  in  the  few  cases  characterized  by  fever  the  symp- 
toms are  by  no  means  severe,  and  the  complications  which  occur  are 
usually  unimportant.  The  prognosis  is  favorable,  and  the  treatment 
ne.ed  consist  in  nothing  more  than  confinement  in-doors  and  intelligent 
supervision. 

SCARLATINA— SCARLET   FEVER. 

Definition. — Scarlatina  is  an  acute,  infectious  disease,  self -limited, 
characterized  by  a  peculiar  exanthem,  an  affection  of  the  throat  and 
albuminuria,  and  terminating  in  desquamation  of  the  epidermis. 

Causes. — Scarlatina,  like  the  other  members  of  the  group,  is  propa- 
gated by  a  peculiar  poison,  which,  by  reason  of  the  tenacity  with 
which  it  adheres  to  articles  of  clothing,  and  other  peculiarities,  we 
have  good  grounds  for  holding  is  a  solid.  It  is  communicated  by 
contact  of  the  healthy  with  the  infected,  and  by  intermediation  of 
various  substances  to  which  the  poison  adheres.  It  occurs  both  in  the 
sporadic  and  epidemic  form,  but  never  arises  spontaneously.  The 
susceptibility  to  scarlatina  is  not  by  any  means  universal,  and  is  less 
than  to  variola  and  measles.  The  time  which  elapses,  from  exposure 
until  the  objective  signs  of  the  disease  are  manifest,  varies  greatly, 
and  is  therefore  very  differently  stated  by  authorities.  The  shortest 
period  is  that  of  a  patient  mentioned  by  Trousseau,  in  whom  the  dis- 
43 


g74:  ERUPTIVE  FEVERS. 

ease  appeared  in  a  day  after  exposure.  The  other  extreme  is  twelve 
to  fourteen  days.  The  most  usual  period  is  from  four  to  seven  days. 
The  very  slightest  contact  with  the  morbific  principle  sufiices.  It  may 
be  conveyed  on  or  about  the  persons  of  the  healthy  to  others  at  a  dis- 
tance. That  it  may  be  dissolved  in  articles  of  food  or  drink  is  ren- 
dered highly  probable  by  the  epidemics  following  in  the  wake  of  milk 
distribution,  of  which  several  very  instructive  examples  have  been 
reported  from  England.  The  poison  is  probably  contained  in  the 
skin  and  its  excretions  and  epithelium,  and  also  in  the  breath  and 
exhalations  from  the  throat.  The  period  of  greatest  activity  of  the 
poison  is  at  the  highest  point  in  the  disease  ;  but  it  is  present  at  any 
period,  from  the  initial  to  the  terminal  symptoms.  The  susceptibility 
varies  greatly,  even  in  members  of  the  same  family,  hence  nothing  is 
more  common  than  for  one  member  of  a  family  to  be  attacked  while  all 
the  rest  escape.  The  susceptibility  to  it  is  increased  by  all  causes  low- 
ering the  vital  forces  ;  and  hence  those  situated  under  unfavorable 
hygienic  conditions  are  more  apt  to  be  attacked.  Again,  the  suscep- 
tibility of  the  same  individual  may  vary  at  different  times.  Within 
the  first  six  months  of  infant  life  there  is  little  liability  to  the  disease ; 
but  the  susceptibility  attains  its  maximum  from  the  second  to  the  fifth 
year,  and  declines  slowly  to  the  tenth,  and  after  this  more  rapidly ;  but 
it  does  occur  in  old  age.  The  author  had  under  his  care  a  gentleman 
of  sixty  years  of  age,  with  scarlet  fever,  after  caring  for  several  of  his 
children  with  the  disease,  and  his  was  a  typical  example.  Sex  and  race 
appear  to  have  no  influence.  Negroes  are  said  to  be  less  susceptible 
than  whites.  The  author  believes  that  this  is  not  true,  the  misconcep- 
tion having  arisen  from  the  difficulty  of  recognizing  the  disease  in  the 
negro.  The  disease  but  rarely  occurs  twice  in  the  same  individual. 
Those  exposed  anew,  especially  if  brought  into  close  relation,  as  in 
the  case  of  mother  and  child,  are  apt  to  suffer  from  the  angina, 
without  experiencing  any  of  the  other  symptoms.  Cases  of  recurring 
scarlatina  are  by  no  means  infrequent ;  the  author  has  seen  two,  in 
which,  from  one  to  three  weeks  after  the  close  of  the  first  attack, 
the  whole  phenomena  of  the  disease  were  repeated,  even  to  the  des- 
quamation. 

Pathological  Anatomy. — The  eruption  may  be  distinct,  and  around 
each  spot  a  border  of  normal  skin  ;  or  it  may  be  confluent,  the  whole 
surface  of  a  vivid  red,  with  punctations  of  a  somewhat  deeper  tint. 
The  eruption  is  due  to  an  intense  hypersemia,  which  is  limited  to  the 
area  of  the  spots,  but  which  is  general  when  the  spots  coalesce.  At 
its  first  appearance  the  eruption  is  less  vivid  than  it  becomes  when 
fully  developed.  The  spots  appear  first  on  the  neck  and  upper  part  of 
the  chest,  then  on  the  face,  where  they  are  also  most  perfectly  de- 
veloped. They  are  nearly  circular,  are  not  elevated  above  the  general 
surface,  and  do  not  therefore  impart  a  roughness  to  the  surface.     They 


SCARLATINA.  675 

are  also  nearly  equal  in  size,  and  when  discrete  uniformly  distributed, 
about  as  much  of  the  integument  being  covered  by  the  eruption  as  free 
from  it.  When  confluent  the  whole  surface  is  a  vivid,  brilliant  red, 
marked,  as  may  be  seen  on  close  inspection,  by  minute  points  of  deeper 
color.  The  eruption  having  reached  the  maximum  of  intensity,  remains 
stationary  from  a  half -day  to  a  day,  and  then  slowly  declines.  When 
the  eruption  first  appears  on  the  face,  the  redness  of  the  temples, 
forehead,  and  cheeks  contrasts  vividly  with  the  pallor  of  the  lips.  The 
eruption  may  be  partial,  or  occur  in  particular  localities,  leaving  large 
portions  of  the  integument  uninvaded.  Thus,  it  may  appear  on  the 
face  only,  on  the  trunk  only,  or  on  the  extremities,  especially  around 
the  joints.  The  individual  spots  may  be  two  or  three  times  as  large 
as  the  usual  eruption.  A  miliary  eruption  of  minute  vesicles  may 
apj)ear  on  parts  so  situated  as  to  sweat  freely,  and  a  very  fine  papular 
eruption  on  all  parts,  notably  on  the  forehead.  In  some  cases  the  cu- 
taneous appearances  are  diversified  by  haemorrhages,  and  the  formation 
of  petechise  and  vibices.  Other  foi-ms  of  eruption  may  complicate 
the  scarlatinal  eruption,  such  as  herpes,  urticaria,  pemphigus,  and 
other  vesicular  and  pustular  affections.  As  the  eruption  disappears, 
boils  may  be  observed,  and  more  or  less  gangrenous  sloughing  may 
occur  in  low  states  of  the  system,  merely  from  pressure.  Desqua- 
mation of  the  epidermis  may  succeed  immediately  to  the  erup- 
tion in  a  few  days,  sometimes  in  a  few  weeks,  after  it  has  disap- 
peared. The  exfoliation  of  the  epidermis  occasionally,  in  severe  cases, 
takes  place  several  times,  and  it  is  usually  general  over  the  body, 
but  the  intensity  of  the  desquamation  is  not  a  measure  of  the  inten- 
sity of  the  exanthem.  The  desquamation  may  consist  of  fine  fur- 
furaceous  scales,  and  of  large  masses  of  exfoliation.  The  thick  and 
hard  epidermis  of  the  hands  and  feet  peels  off  in  large  flakes,  and 
a  cast  of  the  hand  or  foot,  like  a  glove  or  stocking,  is  not  uncom- 
mon. Not  unfrequently  the  hair  and  nails,  and  warts  on  the  fin- 
gers, drop  off.  The  skin  is  left  red  and  sensitive  by  the  desquama- 
tion, but  its  natural  state  is  soon  restored.  Not  less  significant  than 
the  eruption  is  the  affection  of  the  fauces  and  of  the  pharynx.  The 
mucous  membrane  of  the  fauces  is  intensely  hyperaeraic,  of  a  deep-red 
color,  and  marked  by  conical  elevations — swollen  follicles — which 
rarely  in  simple  cases  suppurate  and  discharge.  In  the  severer  cases, 
instead  of  a  simple  redness  there  is  a  more  or  less  deep,  livid  redness, 
involving  not  only  the  fauces,  but  the  whole  mouth  to  the  lips,  the 
pharynx,  and  the  nares.  Besides  the  deep  coloration,  there  are  in- 
creased secretion  and  oedema  of  the  mucous  membrane,  especially  of 
the  soft  palate.  The  tonsils  are  also  deeply  inflamed,  much  swollen, 
and  are  liable  to  form  enormous  purulent  accumulations.  There  is 
a  still  more  formidable  affection  of  the  throat,  in  which,  besides  the 
changes  mentioned  above,  there  are  cedema  of  the  throat,  deep-seated 


676  ERUPTIVE   FEVERS. 

inflammation  of  the  tonsils,  inflammation  of  the  sublingual,  submaxil- 
lary, and  parotid  glands,  and  simultaneous  oedema  of  the  areolar  tissue 
of  the  neck,  the  whole  forming  a  great  mass  of  induration  bulging  out 
from  the  parotid  region,  and  forming  a  broad  band  of  induration  filling 
in  the  whole  space  from  the  chin  to  the  neck.  The  difiiculties  of  the 
case  are  much  enhanced  by  cedematous  swelling  and  inflammation  of 
the  retropharyngeal  connective  tissue  and  that  of  the  larynx.  At  the 
same  time  the  tonsils  may  suppurate  and  slough,  or  become  gangre- 
nous, and  from  the  tonsils  the  suppurative  and  gangrenous  process  may 
extend  in  all  directions,  and  extensive  abscesses  form  in  the  neck,  fol- 
lowed by  immense  sloughing  and  loss  of  tissue.  A  diphtheritic  pro- 
cess may  also  ensue  in  the  fauces  ;  and  so  common  is  it  that  a  close 
relationship  is  supposed  by  many  to  exist  between  them.  The  tongue 
has  a  peculiar  and  very  characteristic  appearance.  It  is  coated  uni- 
formly, except  at  the  tip  and  edges,  with  a  heavy  whitish  or  yellowish- 
white  fur,  increasing  in  depth  toward  the  base.  Through  this  coating 
the  enlarged  papillae  project.  On  or  about  the  third  day  an  entire  ex- 
foliation of  the  coating,  and  of  the  epithelium  also,  takes  place,  leaving 
the  surface  of  the  tongue  raw  and  red,  and  roughened  by  the  elevated 
follicles,  presenting  the  appearance  of  a  fully  ripe  strawberry — whence 
the  term  "strawberry-tongue  of  scarlet  fever."  Troublesome  affec- 
tions of  the  ear  occur  with  those  of  the  throat.  Inflammation  of  the 
middle  ear,  perforation  of  the  drum,  and  in  severe  cases  caries,  pre- 
ceded by  periostitis  of  the  squamous  and  j^etrous  portions  and  of  the 
mastoid  process,  take  place.  Also,  in  severe  cases,  the  tissues  about 
the  ear  externally  are  swollen,  and  pus  dissects  down  the  neck  between 
the  muscular  planes.  Inflammation  of  the  larynx  and  oedema  of  the 
glottis  during  general  dropsy,  bronchitis,  and  pneumonia,  are  the 
lesions  of  the  pulmonary  organs  occurring  during  the  course  of  the 
severer  cases  of  scarlet  fever.  Pericarditis,  endocarditis,  simple  and 
ulcerative,  with  or  without  joint  implication,  are  complications  in  many 
severe  cases.  There  are  no  constant  and  uniform  lesions  of  the  diges- 
tive tube,  pancreas,  or  spleen.  The  kidneys  present,  next  to  the  skin 
and  throat,  the  most  constant  anatomical  changes.  The  tubules  of  the 
kidneys,  like  the  skin,  cast  off  their  epithelium,  which  for  a  time  may 
block  the  passages,  until  at  length  washed  away  by  the  urine  (desqua- 
mative nephritis,  tubular  nephritis,  etc.).  Besides  this,  changes  take 
place  in  the  parenchyma  (parenchymatous  nephritis),  already  sufii- 
ciently  described,  succeeding  to  the  other  form,  and  occurring  in  the 
second  to  the  third  week.  General  dropsy  and  the  accidents  due  to 
ursemia  are  usual  concomitants  of  the  kidney-disease.  Closely  con- 
nected with  the  condition  of  the  blood  due  to  the  kidney-disease,  if  not 
dependent  on  it,  are  the  attacks  of  inflammation  of  the  serous  mem- 
branes and  of  the  synovial  cavities  of  the  joints.  Meningitis,  pleuritis, 
and  peritonitis  are  the  forms  of  serous  inflammation,  and  acute  rheuma- 


SCARLATINA.  Q^'J 

tism  of  synovial.  The  joint  affection  may  consist  only  of  a  little  pain 
and  stiffness,  or  it  may  be  a  severe  attack  of  rheumatism  in  which  all 
the  principal  joints  are  affected  in  turn,  peri-  and  endocarditis  also 
occurring. 

Symptoms. — By  the  older  authors,*  scarlatina  was  divided  into  scar- 
latina niitis  vel  simplex,  scarlatina  anginosa,  and  scarlatina  maligna 
■ — scarlatina  without  any  affection  of  the  throaty  scarlatina  with  de- 
cided implication  of  the  fauces  and  adjacent  lymphatics  ;  scarlatina  of 
the  severest  type  with  extensive  suppuration,  possibly  gangrene.  As 
these  distinctions  are  rather  artificial,  we  purpose  describing  first  the 
ordinary,  well-defined  form,  and  mention  subsequently  the  variations. 
The  period  of  invasion  is  sudden  and  violent.  A  strong  chill  is 
the  initial  symptom  in  adiilts  ;  in  children,  a  violent  convulsion  or  a 
succession  of  them,  or  a  severe  attack  of  vomiting,  with  prostration. 
Headache  of  a  very  intense  character,  general  muscular  pains  and 
high  fever  succeed  to  the  chill.  In  a  short  time  the  temperature 
rises  to  104°,  105°,  or  higher  ;  the  skin  is  tot  and  mordicant ;  the 
throat  burns,  and,  on  inspection,  the  palate,  tonsils,  and  pharynx  are 
red  and  somewhat  swollen  ;  the  tongue  is  coated  with  a  thick  yellow- 
ish fur.  The  fever  is  nearly  continuous  in  type,  and  there  are  no 
strong  remissions  or  intermissions,  as  in  measles.  The  eruption  makes 
its  appearance  usually  at  the  termination  of  the  first  exacerbation  of 
the  fever — at  the  end  of  the  first  or  beginning  of  the  second  day.  It 
appears  on  the  neck  and  upper  part  of  the  chest,  and  then  on  the  cheeks 
and  forehead,  pale,  rose-red,  rapidly  becoming  brighter,  and  at  first 
contrasting  strongly  with  the  white  lips.  Very  quickly,  in  scarcely  a 
half -day,  has  the  eruption  spread  well  over  the  body.  In  the  more 
severe  cases  the  eruption  is  not  completed  until  the  third  or  even 
fourth  day.  When  the  eruption  is  completed  promptly,  it  is  puncti- 
forra,  each  spot  distinct  and  surrounded  by  an  area  of  normal  skin  ; 
when  slower  to  reach  its  maximum,  the  eruption  becomes  confluent 
and  diffused,  the  whole  surface  being  of  an  intense  scarlet  hue.  The 
tongue  is  thickly  coated,  but  the  coating  with  the  epithelium  peels  off 
about  the  fourth  day,  leaving  a  red,  raw  surface,  dotted  with  swollen 
follicles — the  strawberry-tongue.  There  is  no  longer  any  vomiting, 
but  the  appetite  is  wanting,  and  there  may,  be  constipation  or  diar- 
rhoea. Severe  headache  is  experienced  in  the  more  decided  cases  ; 
there  are  apt  to  be  delirium  at  night  and  some  confusion  or  somnolence 
through  the  day.  On  examination  of  the  urine  then,  it  is  found  to  be 
scanty,  high-colored,  smoky,  and  contains  more  or  less  blood  and  albu- 
men. The  eruption  is  barely  completed  before  it  begins  to  fade  on- 
those  parts  where  it  first  appeared — certainly,  it  does  not  stand  at  its 
maximum  longer  than  half  a  day  to  one  day.    The  gradual  disappear- 

*  Gregory's  "  Lectures  on  the  Eruptive  Fevers,"  American  edition  by  Dr.  H.  D.  Bulk- 
ley,  p.  151. 


g78  ERUPTIVE  FEVERS. 

ance  of  the  eruption  is  effected  in  two,  three,  or  four  days,  and  accord- 
ingly the  time  occupied  by  the  eruption  varies  from  three  to  seven 
days  in  its  entirety.  As  the  eruption  fades  away,  the  process  of  shed- 
ding goes  on — at  first,  and  for  a  short  period,  of  a  fine,  furfuraceous 
desquamation,  the  shedding  of  large  scales  being  subsequently  the 
rule  in  most  cases.  The  decline  of  the  eruption  is  coincident  with 
a  diminution  of  the  fever,  and  moderation  of  the  general  symp- 
toms. The  fever  declines  by  lysis — by  a  gradual  lengthening  of  the 
remissions  and  shortening  of  the  exacerbations.  The  pulse  subsides 
with  the  fever,  the  delirium  ceases,  the  skin  becomes  moist,  suda- 
mina  form,  there  is  less  and  less  trouble  with  the  throat,  and  swal- 
lowing becomes  easier  ;  membranous  exudations  are  cast  off,  the  ton- 
sils return  to  their  normal  size  or  nearly  so,  the  tongue  becomes  moist, 
and  its  epithelium  is  reproduced ;  the  appetite  returns  ;  the  urine 
passes  more  abundantly,  and  carries  off  wasted  and  fatty  epithelium, 
the  albumen  disappearing  ;  and  thus,  in  about  ten  to  twelve  days 
from  the  beginning  of  tthe  symptoms,  convalescence  is  established. 
But  few  cases,  however,  go  through  so  mild  a  course.  The  points 
on  which  the  scarlatinal  poison  may  exert  peculiar  force  are  various. 
The  degree  in  which  the  cervical  glands  are  involved  differs  greatly. 
In  the  mildest  there  is  simj^ly  some  slight  tumefaction  of  the  lym- 
phatics in  the  neighborhood  ;  in  the  severest,  the  whole  space  between 
the  chin  and  chest  is  filled  in,  extensive  suppuration  occurs,  slough- 
ing takes  place,  or  more  or  less  gangrene.  Between  these  extremes 
there  are  numerous  gradations  of  severity.  The  throat  affection  may 
be  severe,  and  the  exanthem  light,  and  vice  versa.  It  is  sometimes 
the  case  that,  when  the  throat  affection  is  subsiding  and  the  cer- 
vical glands  are  shrinking  to  the  normal,  a  new  disturbance  arises 
in  the  glands  ;  they  swell  to  a  considerable  size,  fever  comes  on,  and 
convalescence  is  postponed.  In  the  author's  experience  this  reexcite- 
ment  in  the  cervical  glands  is  secondary  to  an  exacerbation  of  the 
renal  troubles.  Great  differences  also  exist  in  the  amount  of  the  kid- 
ney complication.  The  absence  of  objective  evidences  of  kidney-dis- 
ease in  the  urine  does  not  necessarily  imply  a  healthy  state  of  the 
kidneys.  There  are,  however,  very  few  cases  in  which  a  trace  of  albu- 
men is  not  visible.  When  the  hypersemia  of  the  kidney  occurs,  the 
urine,  besides  being  scanty  and  acid,  has  a  smoky  appearance,  from  the 
presence  of  altered  blood-globules  uniformly  distributed  through  it. 
On  cooling,  the  urine  usually  deposits  a  great  quantity  of  urates,  cast- 
off  epithelium  (Figs.  32  and  33),  and  casts  containing  much  of  the  tu- 
bular epithelium.  The  epithelium  and  casts  are  found  at,  or  about,  the 
time  desquamation  of  the  skin  has  commenced.  The  amount  of  albu- 
men, when  it  first  appears,  is  small.  As  the  fever  declines,  and  desqua- 
mation goes  on  favorably,  the  amount  of  urine  discharged  increases  very 
much  ;  it  assumes  a  watery  appearance  and  its  specific  gravity  is  low  ; 


SCARLATINA.  679 

the  albumen  disappears,  and  in  a  short  time  the  urine  becomes  normal. 
Parenchymatous  nephritis  usually  develops  during  the  desquamation 
period,  in  the  third  week,  and  rarely  in  the  second.  Then  the  urine 
becomes  turbid  from  the  presence  of  urates,  blood-corpuscles,  granular 
matter,  casts,  etc.,  is  rather  scanty  and  high-colored,  and  throws  down 
a  great  quantity  of  albumen.  No  absolute  rule  can  be  laid  down  as 
to  the  period  when  the  most  pronounced  renal  symptoms  will  make 
their  appearance,  and  the  time  named  above  must  be  regarded  as 
usual.  The  occurrence  of  renal  changes  is  the  signal  for  other  dis- 
turbances. The  lymphatic  glands  of  the  neck  enlarge  very  much,  the 
appetite  goes,  and  there  are  nausea,  vomiting,  and  constipation,  and 
sometimes  a  severe  diarrhoea.  Violent  headache,  disorders  of  vision, 
hallucinations,  illusions,  muscular  twitchings,  and  eclampsia  are  ex- 
perienced. The  convulsions  may  be  very  violent  in  children,  and 
one  succeed  another,  with  days  of  unconsciousness.  The  eyelids  are 
swollen,  and  the  legs  pit  on  pressure.  The  urine  may  become  very 
scanty,  almost  suppressed.  The  temperature  m.ay  run  very  high, 
and  the  pulse  be  slow,  falling  to  60,  56,  50,  and  even  lower,  or  the 
opposite  conditions  may  prevail — the  temperature  may  be  below  nor- 
mal, and  the  pulse  small,  rapid,  and  feeble.  As  the  symptoms  become 
less  grave,  the  urine  flows  more  abundantly,  but  casts  and  epithelium 
may  be  present  for  some  days,  and  albumen  for  weeks  after  the  disap- 
pearance of  any  apparent  disease. 

Course,  Duration,  and  Termination. — In  the  mildest  form  of  scar- 
latina there  may  be  a  simple  hypersemia  of  the  fauces,  some  swelling  of 
the  submaxillary  glands,  a  transient  fever  of  two  or  three  days'  dura- 
tion, and  the  whole  terminating  in  three  or  four  days.  In  other  cases 
there  may  be  a  pronounced  rash,  but  no  throat  affection,  no  implica- 
tion of  the  kidneys,  and  a  few  days  of  a  mild  fever,  desquamation 
being  almost  entirely  furfuraceous.  But  these  mild  cases  may  be  fol- 
lowed by  albuminuria  and  general  dropsy,  acute  rheumatism,  and 
other  complications.  Sometimes  the  case  seems  of  the  mildest  charac- 
ter at  the  onset,  but  develops  into  a  state  marked  by  all  the  charac- 
teristics of  a  profound  toxaemia.  Others  begin  in  that  way.  At  the 
very  onset,  headache,  delirium,  convulsions,  coma,  tetanic  cramps,  and 
rigidity  of  the  extremities,  uncontrollable  vomiting,  severe  dyspnoea, 
and  a  rapid,  very  feeble  pulse,  indicate  the  severity  of  the  blood-poison- 
ing, and  death  occurs  in  collapse  before  the  eruption  appears.  As  in 
every  epidemic  many  of  the  mild,  insignificant  cases  occur,  so  an  occa- 
sional example  of  all  that  is  most  virulent  in  the  scarlatina-poison  is 
manifested  in  these  cases,  fatal  within  twenty-four  hours  of  their  ap- 
pearing. On  post-mortem  examination  no  lesions  of  importance  are  to 
be  seen,  because  the  changes  are  of  a  subtile  kind,  occurring  chiefly  in 
the  blood.  During  the  course  of  a  perfectly  ftormal  case  of  the  disease, 
symptoms  of  a  very  formidable  character  may  come  on,  consisting  in 


^80  ERUPTIVE   FEVERS. 

sudden  and  great  prostration  of  the  powers  of  life,  the  pulse  becomes 
extremely  weak,  the  eruption  fades,  the  skin  grows  cold,  and  death  usu- 
ally occurs  in  a  few  hours.  In  many  cases,  after  a  satisfactory  course 
to  the  period  of  desquamation,  the  troubles  growing  out  of  a  renal 
complication  begin.  There  are  differences  in  different  epidemics  as  to 
the  liability  to  the  occurrence  of  this  complication.  There  occurs  a 
o-eneral  oedema,  and  dropsical  accumulations  form  in  the  great  cavities, 
especially  of  the  peritoneum.  The  urine  is  scanty,  dark  from  the 
presence  of  blood,  has  a  high  specific  gravity,  and  is  heavily  loaded 
with  albumen.  There  are  present  vomiting  and  purging,  dyspnosa 
from  accumulation  in  the  cavities,  headache,  somnolence,  fever  which 
varies  in  type,  but  is  usually  characterized  by  considerable  remissions, 
the  pulse  being  very  slow  and  irregular.  These  cases  of  scarlatinal 
dropsy  are  usually  quite  fatal,  not  so  much  directly  from  the  kidney- 
lesion,  but  indirectly  from  the  pulmonary  and  intestinal  complications. 
In  other  groups  of  cases,  the  specific  gravity  of  the  uj-ine  falls  very 
low,  and  the  quantity  is  also  very  scanty,  and  may  be  suppressed  even 
for  several  days.  Very  formidable  symptoms  of  urgemic  intoxication 
arise  under  these  circumstances,  including  defects  of  vision  (amblyopia, 
amaurosis,  albuminuric  retinitis  *),  coma,  convulsions  (partial  of  muscles 
of  mouth  and  extremities,  trismus,  and  general).  During  such  attacks 
death  may  ensue  from  the  cerebral  complications,  by  sudden  oedema  of 
the  lungs,  by  exhaustion,  etc.  Although  the  prognosis  is  grave  under 
these  circumstances,  remarkable  recoveries  from  such  states  are  noted 
during  every  epidemic.  When  a  tendency  to  recovery  exists,  the  stupor 
diminishes,  the  convulsions  cease,  the  stomach  becomes  quiet,  and  food 
is  taken,  and  the  urine  becomes  abundant.  There  is  a  great  tendency  to 
relapse,  and  the  change  for  the  worse  is  often  due  to  the  use  of  solid 
and  indigestible  food.  Even  in  those  cases  proceeding  to  a  favorable 
termination,  the  urine  is  found  to  contain  albumen  in  small  quantity, 
after  apparent  entire  recovery.  These  cases  usually  last  from  one  to 
two  or  three  months  before  entire  restoration  is  accomplished.  Other 
cases  are  remarkable  for  the  persistently  high  fever,  the  extent  of  the 
throat  affection,  the  severe  intestinal  troubles,  and  the  cerebral  com- 
plications due  not  to  uraemia,  but  to  the  blood-poisoning.  In  these 
cases,  which  are  often  fatal,  the  result  may  be  due  to  the  consequences 
of  the  high  temperature— reaching  106°,  107°,  108°,  and  even  109° 
Fahr. — while  the  pulse  is  at  200°  ;  to  the  obstruction  to  respiration  in 
the  condition  of  the  throat  ;  to  septicaemia,  cerebral  haemorrhage, 
hydrocephalus,  convulsions,  etc.  ;  or  to  the  exhaustion  caused  by  ex- 
tensive suppuration,  sloughing,  and  gangrene  of  the  throat,  etc.  The 
duration  of  such  cases  will  vary  from  a  few  days  to  a  week,  or  some- 
times longer.     Recurrent  scarlatina  is  a  form  of  the  disease  in  which, 

*  "Die  Albuminurie,"  etc.,  von  Dr.  Hugo  Magnus,  Leipsic,  IS'ZS,  op.  cit. 


SCARLATINA.  ggj 

after  the  whole  process  is  completed  and  convalescence  established, 
there  occurs  an  entire  repetition  of  the  first  seizure,  including  the  des. 
quamation.  The  second  is  somewhat  shorter  and  less  violent  than  the 
first  attack.  Another  irregular  form — to  conclude  the  somewhat  nu- 
merous varieties — is  the  hsemorrhagic.  This  is  one  of  the  most  formi- 
dable varieties  of  the  disease.  The  eruption  is  imjierfectly  developed, 
dark  in  color ;  the  throat  is  much  swollen,  and  diphtheritic  exudations 
occur,  followed  often  by  gangrene  ;  haemorrhages  take  place  from  the 
mucous  surfaces,  from  the  kidneys,  into  the  substance  of  internal  organs, 
from  the  uterus,  etc.  These  cases  are  uniformly  fatal,  death  ensuing 
within  the  first  week.  Any  prognostications  in  regard  to  the  course 
and  termination  of  a  case  of  scarlatina  should  be  guarded,  for  no  dis- 
ease is  more  uncertain.  The  case  may  be  regarded  as  manageable 
when  the  initial  stage  is  not  severe,  the  eruption  appears  at  the  proper 
time,  and  attains  its  maximum  on  the  second  or  third  day,  the  throat 
affection  is  not  extensive,  the  temperature  never  goes  above  104° 
Fahr.,  and  the  pulse  does  not  exceed  140  ;  the  cerebral  symptoms  con- 
sist only  of  a  transient  delirium  at  the  highest  point  of  the  disease  ; 
the  temperature  regularly  and  uniformly  declines  as  the  desquamation 
proceeds  normally,  and  no  other  symptoms  arise.  Certain  complica- 
tions may  exist  without  life  being  put  in  jeopardy.  There  may  be 
mild  complications  of  the  kidney,  and  slight  affections  of  the  joints. 
The  character  of  the  epidemic  is  an  important  factor  in  the  prognosis 
of  individual  cases.  The  mortality  in  different  epidemics  varies  much 
— from  ten  to  forty  per  cent. — and  is  determined  largely,  apart  from 
the  type  of  the  epidemic,  by  the  hygienic  surroundings,  and  especially 
by  age,  infants  succumbing  in  larger  proportion  than  children  and 
young  adults. 

Treatment. — As  scarlatina  is  a  self -limited  disease,  and  as  we  possess 
no  specific  against  it,  our  treatment  must  necessarily  be  symptomatic. 
In  directing  treatment  against  the  symptoms  as  they  arise,  we  may 
select  with  advantage  those  remedies  having  a  power  to  destroy  fer- 
ments. During  every  epidemic  there  are  numerous  mild  cases,  which 
require  only  regulation  of  the  diet,  confinement,  and  supervision  ;  for 
the  mildest  cases  may  be  followed  by  serious  complications.  For  the 
initial  fever,  tincture  of  aconite-root  (half  a  drop  to  a  drop  every  hour, 
according  to  age,  in  a  teaspoonful  of  water),  and,  preferably,  the  tinc- 
ture or  infusion  of  digitalis  (from  one  to  ten  drops  every  two  hours  of 
the  tincture,  or  five  minims  to  a  drachm  of  the  infusion  every  two 
hours),  are  the  most  useful  remedies.  If  the  stomach  is  exceedingly 
irritable,  and  these  remedies  are  rejected,  a  combination  of  carbolic  acid 
and  tincture  of  iodine  is  highly  serviceable  (3.  Tinctura  iodinii,  3  ij, 
acid,  carbolic.  3  j.  M.  Sig.  One  half  a  drop  to  one  or  two  drops  every 
two  to  four  hours  in  water).  If  constipation  exist  at  the  same  time  there 
is  vomiting,  the  usual  condition  during  the  initial  stage,  the  most  effi- 


582  ERUPTIVE  FEVERS. 

cient  laxative  is  calomel — from  one  sixth  to  one  grain  rubbed  up  with 
sugar  and  dropped  on  the  tongue.  During  the  period  of  eruption,  should 
the  surface  be  pale,  the  circulation  feeble,  and  the  eruption  tardy  in 
development,  belladonna  is  the  appropriate  remedy  (from  two  to  ten 
drops  of  the  tincture  every  two  hours),  or,  if  this  fail,  turpentine.  If 
the  temperature  is  very  high  during  the  eruption  stage,  and  there  is 
delirium,  the  kidneys  acting  freely,  the  wet  pack  is  the  most  efficient 
remedy.  If  this  will  not  be  permitted,  or  is  impracticable,  the  skin 
should  be  freely  and  often  sponged  with  cold  water,  and  rubbed  with 
fat — ^lard,  suet,  cacao-butter,  etc.  In  all  cases  when  the  eruption  is 
abundant — is  out  freely — ^the  fat  should  be  used,  the  whole  body  in 
turn  anointed  every  four  hours.  The  effect  of  this  is  to  allay  the 
unpleasant  heat  and  burning  and  to  reduce  the  temperature.  If  vom- 
iting continues  during  this  period,  the  remedies  indicated  for  this  con- 
dition of  things  during  the  stage  of  invasion  are  appropriate  at  this 
period.  Should  diarrhoea  be  present  with  vomiting,  an  excellent  means 
of  arresting  both  consists  in  the  use  of  bismuth  and  carbolic  acid 
{^.  Bismuthi  subnitrat.  3  j  ad  3  ij,  acid,  carbolic,  grs.  ij  ad  grs.  viij, 
mucil.  acacise,  aquse  menth.  pip.,  aa  §  J.  M.  Sig.  A  teaspoonful  every 
two  to  four  hours).  If  the  throat  complication  is  at  all  severe,  the 
best  method  of  treating  it  is  to  apply  wet  compresses,  cold  or  warm, 
to  the  neck,  enveloping  it  with  several  folds.  The  throat  should  be 
frequently  gargled,  if  the  age  permit  it,  with  hot  milk-and-water,  or 
pieces  of  ice  may  be  held  and  allowed  to  melt  slowly,  keeping  them 
well  back  in  the  mouth.  Caustic  applications  should  be  avoided  under 
ordinary  circumstances.  If  sloughing  and  gangrene  are  taking  place, 
strong  solutions  of  nitrate  of  silver,  the  mineral  acids,  solutions  of  car- 
bolic acid,  and  of  permanganate  of  potassa,  chlorate  of  potassa,  etc., 
may  be  used.  If  there  is  much  fetor,  dilute  sulphurous  acid,  iodine, 
and  carbolic  acid  together,  in  solution,  are  effective,  and  may  be  freely 
applied  to  the  fauces,  and  to  all  suppurating  and  sloughing  surfaces. 
If  there  be  active  delirium  during  the  eruption  stage,  the  most  appro- 
priate medicaments  for  the  relief  of  this  condition  are  bromide  of  po- 
tassium, chloral  (if  the  heart's  action  is  good),  morphia,  and  quinine 
in  combination,  if  there  is  anaemia  of  the  brain.  During  desquama- 
tion, the  fat  inunctions  should  be  continued.  Inflammations  of  the 
eye  and  of  the  ear  occurring  at  this  time  should  receive  attention. 
Kidney  complications  demand  treatment  which  shall  be  adapted  to  the 
condition  present.  If  the  urine  is  scanty,  bloody,  and  of  high  specific 
gravity,  if  there  are  pain  in  the  back  and  strong  pulse,  leeches  or  cups 
should  be  applied  to  the  lumbar  region.  Large  draughts  of  water  or 
of  milk,  milk  and  lime-water  if  the  stomach  is  irritable,  cream-of -tar- 
tar lemonade,  infusion  of  digitalis,  topical  application  to  the  lumbar 
region  of  digitalis,  pilocarpine,  etc.,  are  the  most  appropriate  remedies. 
For  further  particulars  of  the  treatment  of  the  kidney  complication, 


DIAGNOSIS.  683 

the  reader  is  referred  to  the  sections  treating  of  these  diseases.  For 
those  eases  exhibiting  profound  alterations  of  the  blood,  the  remedies 
possessing  anti-ferment  powers,  as  carbolic  acid,  salicylic,  benzoate  of 
soda,  thj^mol,  etc.,  may  be  employed.  The  most  useful  of  these,  the 
author  believes,  is  the  combination  of  carbolic  acid  and  iodine,  already 
mentioned.  Extraordinary  results  have  been  claimed  for  the  carbon- 
ate of  ammonia,  and  equally  confident  claims  have  been  put  forward 
for  yeast.  The  character  of  epidemics  varies  so  much  that  caution  is 
necessary  in  accepting  the  conclusions  of  over-confident  therapeutists. 


DIAGNOSIS    OF   VARIOLA,   VARICELLA,    RUBEOLA,   ROSEOLA, 
AND   SCARLATINA. 

To  avoid  repetition,  and  to  make  the  differentiation  as  clear  as  pos- 
sible, the  question  of  the  diagnosis  of  the  above  diseases  has  been  post- 
poned until  they  have  been  considered  in  the  regular  way.  They  may 
be  compared  in  their  period  of  invasion,  stage  of  eruption,  and  stage 
of  desquamation. 

Stage  of  Invasion. — In  small-pox  the  duration  of  the  stage  is  three 
days,  or  until  the  third  exacerbation  of  the  fever  ;  in  measles,  four  days 
or  longer  ;  in  scarlatina,  one  day  or  two.  In  measles  there  is  a  strong- 
ly marked  remission  at  the  end  of  the  second  or  the  beginning  of  the 
third  day — in  small-pox  there  is  no  such  remission  ;  in  measles  the  tem- 
perature does  not  decline  at  the  appearance  of  the  eruption — in  small- 
pox there  is  a  marked  remission  or  an  entire  cessation  of  fever  when  the 
eruption  appears  ;  in  small-pox  the  stage  of  invasion  is  often  diversified 
by  rashes  and  there  is  no  coryza — in  measles  there  is  coryza  but  there 
are  no  initial  rashes.  The  invasion  stage  of  scarlatina  differs  from 
small-pox  in  duration,  in  the  absence  of  any  initial  rashes,  in  the  higher 
temperature,  in  the  coincident  angina,  and  swelling  of  the  lymphatics. 

Stage  of  Eruption. — The  eruption  of  variola  is  first  red  spots,  then 
papules,  then  vesicles,  and  finally  pustules,  and  they  appear  first  on 
the  face,  forehead,  and  head  ;  that  of  measles  is  reddish,  lenticular 
spots,  slightly  elevated  above  the  skin,  and  imparting  a  sense  of  rough- 
ness to  the  surface  ;  that  of  varicella,  vesicles  ;  that  of  roseola,  rose- 
red  spots  like  measles,  but  not  so  prominent ;  that  of  scarlatina,  bright- 
red  spots  and  diffused  redness,  with  punctations  of  deeper  red.  The 
eruption  of  small-pox  on  its  appearance  has  an  indurated  feel,  as  of  a 
solid  body — a  bird-shot — in  the  skin  ;  that  of  measles  imparts  a  sense 
of  roughness  wholly  on  the  surface  ;  that  of  varicella  has  to  the  touch 
the  sensation  of  a  vesicle  elevated  above  the  surface  ;  and  that  of  scar- 
latina has  no  roughness,  but  is  a  vivid  scarlet-red  spot,  which  disap- 
pears on  pressure,  to  return  as  soon  as  the  pressure  is  removed.  The 
eruption  of  small-pox  requires  many  days  to  develop,  and  its  matura- 
tion is  accompanied  by  distinct  fever  ;  that  of  measles,  roseola,  vari- 


684  ERUPTIVE  FEVERS. 

cella,  and  scarlatina  reaches  its  maximum  in  a  day  or  two.  The  eruption 
of  measles  is  accompanied  by  coryza,  watering  of  the  eyes,  a  coarse, 
bronchial  cough — that  of  scarlatina  by  sore-throat  and  swelling  of  the 
submaxillary  and  sublingual  and  cervical  glands  ;  both  desquamate — 
the  former  in  fine,  furfuraceous  scales,  often  not  perceptible — the  latter 
in  large  flakes  and  very  distinctly.  The  pustule  of  small-pox  forms  a 
distinct  crust  and  leaves  a  scar  ;  that  of  varicella  dries  up  and  drops 
off  without  a  mark.  The  eruption  of  measles  differs  from  roseola  in 
that  the  former  is  darker  in  color,  is  accompanied  by  fever,  coryza, 
etc.,  not  present  in  the  latter. 

Stage  of  Desquamation. — Desquamation  occurs  in  both  measles  and 
scarlatina,  but  differs  greatly  in  thoroughness,  as  is  above  stated.  The 
complications  of  this  period  are,  in  scarlatina,  affections  of  the  kidneys, 
dropsy,  uraemia,  etc.  ;  of  measles,  catarrhal  pneumonia,  capillary  bron- 
chitis, and  ileo-colitis.  Desquamation  does  not  occur  in  small-pox  until 
the  pustules  have  matured  and  crusts  formed. 


ERYSIPELAS. 

Definition. — Erysipelas  is  a  self-limited,  febrile  affection,  charac- 
terized by  a  local  inflammation  of  the  skin,  terminating  in  desquama- 
tion, and  accompanied  by  constitutional  symptoms  and  the  usual  phe- 
nomena of  blood-poisoning. 

Causes. — The  most  influential  factor  in  its  propagation  is  contagion. 
It  prevails  in  hospitals,  and  epidemics  follow  in  the  paths  of  armies. 
A  peculiar  poison,  it  is  assumed,  enters  a  wounded  surface,  and,  after 
a  certain  period  of  incubation,  the  phenomena  of  the  disease  follow 
(Trousseau).  Nevertheless,  the  disease  has  been  divided  into  two 
classes — idiopathic  and  traumatic — the  former  arising  spontaneously, 
the  latter  in  connection  with  a  wound.  That  this  distinction  must 
still  be  maintained  is  probable,  because  there  are  many  cases  of  ery- 
sipelas for  which  there  is  no  traumatic  cause,  and  which  must  be, 
therefore,  idiopathic.  It  is  asserted  that  women  are  more  susceptible 
to  the  poison  than  men  ;  but  later  researches  have  shown  the  incorrect- 
ness of  this  statement.  It  is  a  disease  of  all  ages,  but  is  rather  more 
usual  from  the  twentieth  to  the  forty-fifth  year  of  life.  It  occurs 
at  all  seasons,  but  is  more  prevalent  during  the  variable  weather  of 
winter  and  spring.  The  author  has  witnessed  two  ej)idemics  of  ery- 
sipelas and  puerperal  fever,  occurring  together,  and  acting  apparently 
in  substitution. 

Pathological  Anatomy. — The  whole  thickness  of  the  skin  is  in- 
volved, and  the  inflammation  extends  through  to  the  subcutaneous 
connective  tissue.  The  derma  is  bare  by  exfoliation  of  the  epidermis 
and  uppermost  cells  and  the  papilla  ;  and  the  connective  tissue,  with 
the  sweat  and  sebaceous  glands,  is  (edematous  and   infiltrated   with 


ERYSIPELAS.  685 

white  blood -corpuscles  in  great  numbers.  By  the  accumulation  of 
cells  an  abscess  forms  at  the  summits  of  the  papillae.  As  soon  as  the 
redness  in  the  skin  subsides,  the  cells  thickly  distributed  through  the 
subcutaneous  tissue  undergo  a  granular  disintegration  ;  a  portion  of 
the  detritus  thus  produced  enters  the  lymph-vessels,  and  the  rest 
are  absorbed,  leaving  the  skin  normal.  Various  changes  have  been 
reported  as  occurring  in  internal  organs  ;  but  little  definite  informa- 
tion exists  in  regard  to  them,  except  granular  degeneration  of  the 
heart  and  vessels,  the  liver,  kidneys,  and  spleen,  which  appears  to  be 
definitely  established.  The  blood  seems  to  be  much  changed,  but  the 
reports  are  not  uniform  as  to  the  character  of  the  alterations.  Bas- 
tian  has  ascertained  the  existence  of  capillary  embolisms  of  the  cere- 
bral vessels,  in  some  cases  of  death,  from  erysipelas  of  the  face. 

Symptoms. — Like  the  other  eruptive  fevers,  erysipelas  sets  in  by  a 
stage  of  invasion.  The  initial  symptom  is  a  chill,  although  not  usu- 
ally a  violeiit  chill.  Headache,  often  of  an  intense  character,  comes 
on  Avith  the  fever  ;  and  there  are  nausea,  bilious  vomiting,  and  entire 
loss  of  appetite.  Before  the  eruption  ajDjaears,  and  thus  directing  the 
diagnosis,  some  of  the  cervical  lymphatics,  or  the  submaxillary  gland, 
swells — the  former  when  the  erysipelas  appears  on  the  head,  and  the 
latter  when  it  attacks  the  face.  That  this  sign  shall  be  available,  the 
initial  stage  must  be  longer  than  a  half -day.  A  sense  of  heat  and 
tension  is  felt  in  the  skin  which  is  about  to  become  inflamed.  A 
patch  of  redness  appears,  and  at  several  points,  which  coalesce  and 
thence  spread  widely.  The  red  color  disappears  on  pressure,  to  be 
quickly  restored  ;  but,  when  the  red  disappears,  a  yellowish  rather 
than  white  hue  is  seen.  The  skin,  inflamed,  is  also  (edematous,  and  it 
presents  a  tense,  shiny  appearance.  The  redness  may  commence  at 
any  point  on  the  face  or  scalp,  but  it  usually  takes  its  origin  from 
some  accidental  abrasion  or  from  a  pathological  lesion,  as  a  patch  of 
eczema,  or  impetigo,  etc.  ;  and,  when  not  initiated  by  such  cause,  it  is 
apt  to  begin  at  or  near  one  of  the  cavities  opening  externally — at  the 
mouth,  nose,  or  meatus  auditorius.  It  was  the  opinion  of  the  late 
Dr.  Todd  that  many  cases  of  erysipelas  begin  in  the  fauces  and  spread 
thence  to  the  lips  and  elsewhere.  The  appearance  of  the  eruption  is 
accompanied  by  a  sensation  of  heat,  burning,  and  tension,  and  some- 
times there  is  acute  pain  in  the  affected  part.  Where  the  parts  are 
lax,  and  the  exudation  has  room,  there  is  less  pain,  and  the  swelling, 
therefore,  is  inversely  as  the  pain.  When  there  is  great  distention,  and 
also  abundant  and  rapid  exudation,  the  epidermis  is  raised  into  blis- 
ters of  varying  size,  according  to  the  state  of  the  skin.  These  blisters 
contain  a  transparent  serum  ;  sometimes  they  are  reddish  from  the 
presence  of  blood,  or  yellowish  from  the  number  of  pus-coi-puscles,  and 
they  contain  great  numbers  of  bacteria.  Where  the  cellular  tissue  per- 
mits, the  swelling  may  be  enormous,  and  the  head  and  face  so  trans- 


686  ERUPTIVE  FEVERS. 

formed  that  not  a  single  feature  is  recognizable  ;  the  eyes  can  not  be 
opened,  the  nose  is  closed,  and  the  lips  so  stiff  and  swollen  as  scarcely 
to  permit  of  feeding.  The  inflammation  reaches  its  highest  point  on 
the  second  or  third  day,  when  the  retrograde  process  begins,  and  on 
the  fourth,  fifth,  or  sixth  day  the  redness  is  fading  and  the  color  is 
becoming  yellow,  and  less  and  less  swelling  is  noted.  The  blebs  dry 
into  yellow  scabs  or  crusts.  Suppuration  may  take  place  at  various 
points  after  the  termination  of  the  inflammation  in  the  skin,  but  the 
pus  is  usually  absorbed  without  difiiculty.  Desquamation  of  the  epi- 
dermis takes  place  over  the  whole  area  occupied  by  the  inflammation, 
and  the  hair  drops  out,  to  be,  however,  quickly  reproduced.  During 
the  maximum  of  the  inflammation  the  scalp  is  very  tender,  and  much 
pain  is  experienced  wherever  the  head  rests.  The  great  peculiarity  of 
erysipelas  is  its  migratory  character,  spreading  widely  from  the  point 
where  it  first  appeared  to  distant  parts  of  the  body.  The  margin  of 
the  redness  is  not  sharply  defined,  but  the  swelling  forms  an  abrupt 
ridge.  The  diffusion  of  the  inflammation  is  not  a  mere  chance,  but 
pursues  its  course  along  the  lines  of  least  resistance,  as  determined  by 
the  arrangement  of  the  fibrous-tissue  bundles.  The  opinion  of  Todd, 
that  erysipelas  may  start  from  an  inflammation  of  the  fauces,  is  sup- 
ported by  Trousseau  and  other  authorities,  and  the  erysipelas  may 
extend  downward  into  the  glottis.  The  mucous  membrane  may  also 
be  attacked  secondarily  by  extension  of  the  inflammation  from  the  skin. 
A  heavily  coated  tongue,  whitish  or  yellowish-white,  becoming  blackish, 
and  ultimately  peeling  off  in  large  flakes,  is  the  condition  of  this  organ. 
There  are  usually  much  nausea,  protracted  vomiting,  entire  loss  of  ap- 
petite, and  excessive  thirst.  The  intestinal  evacuations  may  be  nor- 
mal, or  diarrhoea  may  be  present,  or  black,  foul-smelling,  imhealthy 
discharges  may  occur.  Ulcerations  of  the  duodenum,  and  consequent- 
ly intestinal  haemorrhage,  are  by  no  means  uncommon.  The  urine  may 
contain  albumen  and  casts,  and  indeed  a  small  quantity  of  albumen 
seems  an  invariable  result ;  hence  ursemia,  with  all  its  possibilities, 
may  enter  into  the  symptomatology  of  erysipelas.  There  are  few 
cases  of  severe  erysipelas  without  some  transient  delirium.  Often 
there  is  active  delirium  during  the  highest  point  in  the  case.  There 
are  three  chief  sources  of  the  delirium :  cerebral  anaemia,  a  reflex  re- 
sult of  the  cutaneous  inflammation  ;  alcoholic  excess  ;  thrombosis  of 
the  capillaries,  or  sinuses.  The  two  first  named  may  or  may  not  be 
important ;  the  last  is  probably  always  fatal.  Fortunately,  it  is  rare. 
It  was  Bastian,  we  believe,  who  first  pointed  out  the  capillary  throm- 
boses resulting  from  facial  erysipelas.  The  explanation  is  afforded 
by  the  intimate  anatomical  connection  of  the  facial  vein  with  the 
pterygoid  plexus  and  cavernous  sinus.  Delirium  is  also  a  result  of 
continued  high  temperature,  but  more  especially  a  result  of  a  combina- 
tion of  high  fever  with  cerebral  anaemia,  the  patient  one  who  had  been 


ERYSIPELAS.  63Y 

addicted  to  alcoholic  excess.  At  the  onset  of  the  inflammation  the 
fever  may  reach  104°  or  105°  Fahr.  The  type  of  the  fever  is  remit- 
tent, and  a  rapid  defervescence  ensues  usually  about  the  fourth,  fifth, 
sixth,  or  seventh  day  ;  but  this  defervescence  is  determined  by  the  ces- 
sation of  the  inflammation  in  the  skin.  If  the  eruption  continues  to 
spread,  there  will  be  fluctuations  in  the  temperature  corresponding  to 
the  varying  condition  of  the  skin.  The  pulse  corresponds  and  ranges 
from  100  to  140. 

Course,  Duration,  and  Termination. — Erysipelas  corresponds  to  the 
other  eruptive  diseases,  in  its  tendency  to  spontaneous  cure  at  a  certain 
period,  but  this  is  less  certain,  owing  to  its  erratic  course  over  the  skin. 
The  usual  duration  is  from  one  to  three  weeks,  but  it  may  continue 
much  longer  when  it  tends  to  spread  over  a  large  part  of  the  integu- 
ment. When  it  ceases,  in  that  which  may  be  regarded  as  the  typical 
mode,  on  the  fourth,  fifth,  or  sixth  day,  by  a  rapid  defervescence  of  the 
temperature,  there  often  occurs  some  critical  evacuation — a  profuse 
sweat,  free  intestinal  movements  of  a  very  offensive  character,  or  a 
large  urinary  evacuation  ;  but  these  critical  phenomena  are  not  always 
present.  Primary  or  idiopathic  erysipelas,  notwithstanding  the  hor- 
rible aspect  presented  by  the  patient  and  the  occurrence  of  considerable 
delirium,  usually  terminates  in  recovery.  The  convalesence  is  rather 
tedious  because  of  the  low  condition  to  which  the  patient  is  reduced, 
even  in  favorable  cases.  There  are  dangers,  fortunately  rather  rare, 
which  attend  the  primary  form  of  the  disease — the  occurrence  of  capil- 
lary thromboses,  or  of  the  sinuses  ;  the  formation  of  ulceration  in  the 
duodenum  ;  the  extension  of  the  inflammation  to  the  fauces  ;  and  the 
depression  of  the  powers  of  life,  which  may  coincide  with  the  sudden 
defervescence  of  the  temperature.  The  traumatic  form  is  more  seri- 
ous, because  the  erysipelatous  inflammation  is  added  to  the  complica- 
tions of  the  injury.  Furthermore  the  local  hygienic  conditions  sur- 
rounding the  wounded  are  favorable  to  the  development  of  serious 
complications.  Erysipelas  coming  on  during  convalescence  from  such 
serious  diseases  as  typhoid,  pneumonia,  diseases  of  the  heart,  diabetes, 
etc.,  is  always  a  very  dangerous  malady.  On  the  other  hand,  impor- 
tant complications  may  arise  during  the  course  of  an  ordinary  erysipe- 
las. Thus  a  pneumonia,  pleuritis,  peritonitis,  or  meningitis,  may  arise 
by  extension  of  the  disease.  Although  the  connection  between  the 
external  malady  and  the  disease  within  can  not  always  be  traced,  it 
probably  exists.  Finally,  an  attack  of  erysipelas  may  terminate  in 
pyfemia. 

Diagnosis. — Erysipelas  may  be  confounded  with  erythema,  urticaria, 
and  with  phlegmonous  erysipelas.  Erythema  is  a  superficial  redness 
without  inflammation — without  heat  and  swelling — is  without  fever, 
and  does  not  desquamate.  Urticaria  occurs  in  the  form  of  wheals 
that  itch  a  good  deal  and  disappear  in  a  few  hours.     Phlegmonous 


688  ERUPTIVE  FEVERS. 

erysipelas,  so  called,  is  a  deep-seated  inflammation,  with  suppuration, 
spreading  along  the  connective  tissue  and  by  the  intramuscular  planes 
from  a  wound  or  injury,  and  does  not  take  the  course  along  the  integu- 
ment, as  erysipelas.  So  characteristic  are  the  appearance  and  behav- 
ior of  erysipelas  that  it  would  seem  impossible  to  mistake  it  for  any 
other  disease.  The  diagnosis  by  anticipation  should  not  be  overlooked 
— the  occurrence  of  enlarged  lymphatics  in  the  neck  in  the  case  of  ery- 
sipelas of  the  scalp,  and  of  enlarged  submaxillary  glands  in  the  case 
of  erysipelas  of  the  face. 

Treatment. — The  perturbating  treatment  formerly  used  is  now  no 
longer  employed.  The  mildest  cases  require  only  a  laxative,  a  suit- 
able diet,  and  the  local  application  of  some  vaseline  to  abate  the  heat 
and  burning.  In  the  more  severe  cases  there  can  be  no  doubt  of  the 
value  of  quinia,  especially  if  combined  with  belladonna.  To  avoid  the 
complications  which  may  arise  in  even  sim^Dle  cases,  the  author  gives 
the  tincture  of  belladonna,  or  preferably  a  solution  of  atropia  (atropiae 
sulph.  gr.  j,  aquae  3  j.  M.  Sig.  One  drop  every  four  hours  in  some 
water).  As  the  effect  of  the  atropia  accumulates,  the  interval  between 
the  doses  is  enlarged.  In  the  more  severe  cases  quinia  should  always 
enter  into  the  treatment,  and  in  full  medicinal  not  antipyretic  doses 
(]^.  Quinsesuli^h.  3ij,  ext.  belladonnse  gr.  iij.  M.  Ft.  xpil.  Sig.  One 
every  four  hours).  The  delirium  of  anaemia,  the  usual  form,  espe- 
cially in  those  addicted  to  alcoholic  excess,  is  best  relieved  by  alco- 
holic stimulants,  and  morphia  and  belladonna,  if  the  latter  does  not 
enter  into  some  other  combination.  The  systematic  use  of  milk  and 
beef-essence  is  necessary  in  all  severe  cases,  esj)ecially  under  the  con- 
ditions named  above.  Tincture  of  chloride  of  iron,  in  half -drachm 
doses  every  four  hours,  is  much  commended  by  the  English  physi- 
cians, and  with  good  reasons.  In  traumatic  erysipelas  Mr.  Higgin- 
botham's  mode  of  applying  a  solution  of  silver  nitrate  in  nitric  ether 
is  most  serviceable.  The  surface  must  be  carefully  washed  and  dried. 
Then  the  following  solution  is  brushed  over  the  inflamed  area,  and  for 
a  short  distance  beyond  on  the  healthy  skin.  On .  drying,  should  any 
part  of  the  skin  appear  untouched,  the  solution  is  reapplied  to  these 
parts.  The  usual  strength  is  about  as  follows  :  T^.  Argenti  nitrat.  3j, 
spts.  aetheris  nitrosi  3  ij.  M.  Sig.  Apply  with  a  brush.  An  aqueous 
solution  of  two  drachms  to  the  ounce  may  be  employed  instead.  The 
topical  applications  employed  are  almost  innumerable — a  fact  which 
indicates  the  uncertainty  of  value  of  any  article.  As  a  rule,  irritating 
applications  do  more  harm  than  good.  To  this  dictum  must  be  ex- 
cepted the  application  of  nitrate  of  silver,  in  the  traumatic  form  of  the 
disease.  The  author  has  seen  mercurial  ointment,  diluted  ten  times 
with  lard,  very  successful.  Probably  still  better  is  the  following  : 
Vaseline  3  j,  acid,  carbolic.  3  ss.,  or  less,  which  should  be  brushed  over 
the  inflamed  area  three  or  four  times  a  day.     Above  all  remedies  and 


TYPHOID  FEVER.  689 

applications  is  the  use  of  a  nutritious  diet.  From  the  very  beginning 
systematic  feeding  should  be  carried  on.  When  the  patient  can  retain 
nothing  else,  lime-water  and  milk  may  be  retained.  But,  when  the 
stomach  becomes  quiet,  milk,  eggs,  animal  broths,  etc.,  should  be  given 
at  regular  intervals,  and,  when  necessary,  stimulants.  Trousseau  {op. 
cit.)  used  no  remedies  except  a  laxative,  but  he  pushed  the  adminis- 
tration of  food,  and  of  the  great  number  of  cases  treated  by  him  only 
three  died. 


FEYERS. 


TYPHOID  FEVER. 

Definition. — Typhoid  fever  is  an  acute  febrile  affection,  self -limited, 
feebly  if  at  all  contagious,  and  characterized  by  a  peculiar  eruption 
on  the  abdomen,  by  a  form  of  diarrhoea,  by  stupor  and  low  delirium, 
by  thickening  and  ulceration  of  Peyer's  patches,  by  infiltration  and 
softening  of  the  associated  mesenteric  glands,  and  by  swollen  spleen. 
Various  names  have  been  applied  to  this  disease.  In  Germany  *  and 
France,t  and  on  the  Continent  generally,  it  is  now  called  "  abdominal 
typhus  "  ;  in  England  and  this  country  it  is  usually  designated  typhoid 
or  enteric  fever,  the  term  which  was  originally  proposed  by  the  late 
Professor  George  B.  Wood.  Notwithstanding  the  term  typhoid  is 
excessively  faulty,  it  is  so  universally  used  in  this  country  that  the 
author  has  adopted  it. 

Causes. — Typhoid  owes  its  origin  to  a  peculiar  poison,  whose  source 
and  nature  have  thus  far  eluded  investigation,  but  is  associated  with 
the  decomposition  of  animal  matter  under  certain  conditions.  It  is 
never  produced  by  mere  decomposition  of  animal  matter,  faeces,  or 
the  contents  of  sewers  ;  it  is  essential  to  the  formation  of  the  poison 
that  the  typhoid  genu  be  present,  and  this  germ  finds  in  these  decom- 
posing animal  matters  a  suitable  soil  for  its  growth  and  development. 
It  does  not  originate  de  novo,  but  there  must  be  present  some  typhoid 
matter  furnishing  the  material  for  a  new  growth.  There  are  sound 
reasons  for  concluding  that  the  poison  is  contained  in  the  excrements, 
but  it  seems  necessary  for  some  change  to  go  on  in  the  excreta  to 
develop  the  activity  of  the  poison,  for  when  in  the  fresh  state  they 

*  "Handbuch  der  Pathologie  und  Therapie  des  Fiebers,"  von  Dr.  C.  Liebermeister, 
Leipsic,  1875,  p.  690.     Ibid.,  Ziemssen's  "  Cyclopsedia." 

\  "  Traite  de  Pathologie  Interne,"  par  S.  Jaccoud,  Paris,  1811. 
44 


690  FEVERS. 

manifest  no  actiyity.  Admitted  to  the  cesspool,  or  to  the  sewer,  or 
thrown  on  the  ground,  the  poison  becomes  active  and  multiplies,  so 
that  the  excretions  of  a  single  patient  may  multiply  sufficiently  to  poi- 
son a  large  community.  The  poison  of  typhoid  is  extremely  viable,  and 
preserves  its  activity  for  a  long  time,  so  that,  should  typhoid  occur  in 
a  given  locality  and  then  disappear  for  a  long  time,  another  epidemic 
may  develop  without  the  introduction  of  a  new  case.  How  long  the 
poison  may  remain  in  the  body  before  the  advent  of  symptoms  can 
not  be  very  definitely  established.  The  average  duration  of  the  incu- 
bation period  may  be  stated  at  three  weeks,  although  it  may  be  as 
short  as  one  week,  or  as  long  as  four.  The  vehicles  by  which  the  dis- 
ease-germs reach  the  body  are  air,  water,  articles  of  food,  etc.  In  the 
gaseous  exhalations  from  the  sewers  and  privies,  the  materies  tnorbi  is 
carried  up  ahd  is  inhaled  ;  dissolved  in  drinking-water  or  in  milk,  it  is 
conveyed  into  human  stomachs,  and  it  may  be  deposited  on  other  arti- 
cles of  food  to  be  similarly  disposed  of.  That  the  inateries  morbi  does 
not  infect  a  larger  number  is  probably  due  to  the  insusceptibility  of 
many  persons  receiving  it.  Susceptibility  to  the  poison  is  developed  by 
various  influences.  The  seasons  have  the  power  to  modify  the  preva- 
lence of  the  disease.  In  this  country  the  fall  and  winter  are  seasons  of 
the  greatest  prevalence  of  typhoid.  Loomis  *  says  it  is  most  prevalent 
in  autumn,  whence  it  is  known  as  "  autumnal  fever."  The  condition  of 
the  water-supply,  as  to  its  elevation,  Buhl  has  shown  for  Munich,  is  an 
important  element,  and  that  typhoid  decreases  as  the  water  rises,  and 
increases  as  the  water  falls.  Age  affects  the  predisposition  to  typhoid, 
and  the  tendency  to  it  is  greatest  from  fifteen  to  thirty  years  ;  it  is 
almost  absent  in  children  under  one  year  and  in  the  aged.  Men  are 
rather  more  susceptible  than  women,  and  the  disease  selects  by  pref- 
erence the  most  vigorous  and  able-bodied,  and  passes  by  those  suffering 
from  chronic  diseases.  One  attack  furnishes  exemjrtion  against  those 
in  the  future,  but  this  rule  is  frequently  violated.  Recurring  typhoid, 
however,  like  recurring  scarlatina,  is  not  uncommon. 

Pathological  Anatomy. — The  lesions  of  typhoid  fever  are  eminently 
distinctive.  The  extent  of  the  changes,  although,  as  a  rule,  indicative 
of  the  violence  of  the  attack,  is  not  always  so  ;  for  with  comparatively 
few  lesions  there  may  be  formidable  symptoms,  and  vice  versa.  As  it 
is  probable  that  the  poison  enters  the  intestinal  canal,  and  there  begins 
its  ravages,  it  is  most  appropriate  to  begin  the  sketch  of  the  morbid 
anatomy  with  the  intestinal  lesions.  The  title  dothienenterie,  first 
given  to  this  disease  by  Bretonneau,  and  adopted  by  Trousseau,f  was 
intended  to  emphasize  the  importance  and  particularity  of  the  intestinal 
lesions.     Following  the  descriptions  of  Trousseau  and  of  Liebermeis- 

*  "  Lectures  on  Fevers,"  by  Alfred  L.  Loomis,  A.  M.,  M.  D.,  New  York,  William  "Wood 
k  Co.,  1877,  p.  403. 

■j-  "  Clinique  Medicale,"  tome  premier,  Paris,  1865,  p.  212,  et  seq. 


TYPHOID  FEVER.  691 

ter,  who  pursued  a  chronological  arrangement,  we  may  divide  the  ap- 
pearances into  periods  of  weeks.  In  the  first  week  there  are  more  or 
less  hyperoemia  and  swelling  of  the  mucous  membrane  in  the  ileum 
at  its  lower  part,  and  especially  around  the  patches  of  Peyer.  Coinci- 
dently,  a  few  of  Peyer's  glands  and  some  solitary  follicles  are  swollen 
by  infiltration,  especially  those  glands  near  to  the  ileo-csecal  valve, 
and  by  the  end  of  the  first  week  the  infiltration  has  become  general. 
The  congestion  is  not  limited  to  the  mucous  membrane,  but  often  ex- 
tends to  the  peritoneal  surface,  which  is  intensely  hypersemic  (Lyons  *), 
to  the  mesentery,  and  to  the  spleen.  In  the  second  week  occurs  the 
infiltration  of  the  glands  of  Peyer,  and  the  hyperaemia  lessens.  Stim- 
ulated, we  may  suppose,  by  the  typhoid-poison,  the  cellular  elements 
of  the  glands,  agminated  and  solitary,  undergo  a  rapid  proliferation, 
by  multiplication  of  their  nuclei  and  by  division.  This  increase  of 
their  contents  causes  them  to  swell  in  all  directions,  so  that  they  rise 
above  the  general  surface  of  the  intestine,  and  appear  dark  or  reddish. 
The  solitary  follicles  vary  in  size  from  half  a  line  to  a  line  in  diameter, 
to  the  volume  of  a  small  pea,  and  may  even  reach  the  dimensions  of  a 
bean,  while  the  patches,  oval  in  shape,  are  elevated  above  the  surface, 
from  one  sixteenth  to  one  quarter  of  an  inch.  The  new  cells  are  not 
confined  to  the  glands  entirely,  but  wander  forth,  infiltrating  the 
neighboring  mucous  membrane,  and,  passing  through  the  muscular, 
penetrate  to  the  subserous  layer.  At  and  near  to  the  ileo-cgecal  valve, 
a  number  of  the  patches  cohere  and  unite,  forming  oblong  masses,  and 
even  surrounding  the  valve  with  a  ring.  The  patches  also  coalesce  at 
the  extremity  of  their  long  axis,  parallel  to  the  long  axis  of  the  intes- 
tine, and  thus  attain  extraordinary  length.  The  number  infiltrated  is 
not  always  the  same  ;  they  may  all  be  involved  to  a  greater  or  less 
extent  ;  there  may  be  but  three  or  four.  The  same  differences  exist 
in  respect  to  the  number  of  solitary  follicles  infiltrated.  The  rapid  and 
large  production  of  new  cells  imparts  to  the  glands  and  follicles  a  soft, 
spongy  character,  and  soon  leads  to  a  necrotic  softening  and  sloughing. 
It  is,  however,  in  the  more  pronounced  cases  that  the  patches  become 
necrotic.  They  have  usually  a  greenish  color,  from  the  presence  of 
bile-pigment,  or  are  stained  a  brownish  color  by  the  intestinal  juices. 
The  sloughs  are  cast  off  during  the  second  week,  leaving  an  ugly  exca- 
vation which  reaches  to  the  muscular  coat,  and  often  to  the  serous. 
These  ulcers  have  the  shape  and  size  of  the  involved  patches,  and  are 
elliptical  in  form,  their  long  diameter  parallel  to  that  of  the  intestine, 
and  their  margins  are  thick  and  sharply  defined.  Enormous  ulcers 
may  form  in  the  neighborhood  and  around  the  valve,  by  the  imion  of 
many  ;  indeed,  this  part  may  be  a  mass  of  ulcerations,  with  small  bits 
of  mucous  membrane  between  them.     The  process  of  ulceration  and 

*  "  Treatise  on  Fever,"  Philadelphia,  1S61,  p.  362. 


692  FEVERS. 

necrotic  sloughing  may  be  postponed  to  a  mucli  later  period.  Several 
months,  indeed,  may  be  occu^Died  in  the  process  of  typhoid  infiltration, 
without  ulceration  taking  place  (Lyons).  But  such  examples  are  clearly 
exceptional.  When  extrusion  has  taken  place,  the  process  of  healing 
goes  on  in  favorable  cases.  The  floor  of  the  ulcer  is  soon  covered  with 
granulations,  and,  a  gradual  contraction  taking  place,  the  ulcer  is  ulti- 
mately closed,  a  cicatrix  marking  the  site.  A  restoration  to  the  nor- 
mal is  accomplished  in  many  patches  and  follicles  without  ulceration. 
The  new  cells  disintegrate  and  disappear,  the  hypersemia  subsides,  and 
the  original  state  is  resumed.  It  is  probable  that  this  is  the  course  of 
the  lesions  in  the  mildest  cases.  The  two  processes  are  usually  mixed. 
Amid  more  or  less  extensive  sloughing  and  destruction  of  substance, 
there  will  be  seen  patches  and  follicles  that  do  not  ulcerate,  and  whose 
new  elements  degenerate  and  are  absorbed.  The  part  of  the  intestine 
affected  has  an  influence  on  the  result — the  sloughing  and  ulceration 
taking  place  below,  and  the  retrogression  by  degeneration  and  absorp- 
tion occurring  above.  The  j)rocess  of  sloughing  and  repair  may  go 
on  together,  and  at  a  very  advanced  period,  so  that  perforation  may 
result  when  healing  is  far  advanced. 

It  has  already  been  mentioned  that  the  initial  hyper semia  involved 
the  mesentery  as  well  as  the  intestines.  Other  changes  occur  in  the 
mesentery,  following  in  the  wake  of  those  going  on  in  the  intestine. 
The  glands  swell,  are  congested,  reddish,  and  succulent.  They  enlarge 
very  considerably  by  an  accumulation  of  their  contents,  and  attain  the 
size  of  a  bean,  an  almond,  or  a  pigeon's-egg.  They  presently  soften, 
and  many  become  diffluent  and  are  barely  retained  within  the  capsule. 
When  retrogression  takes  place  the  soft  material  is  absorbed,  the  con- 
gestion disajDpears,  and  the  glands  shrink  to  their  normal  size.  Some- 
times a  purulent  collection  remains  behind,  and  a  slow,  cheesy  trans- 
formation is  effected.  It  not  unfrequently  happens  that  other  lym- 
phatic glands  are  infiltrated  to  some  extent,  such  as  the  retroperito- 
neal and  bronchial  glands,  etc.,  but  in  the  mesentery  the  glands  usually 
attacked  are  those  immediately  related  to  the  diseased  part  of  the  in- 
testine, although  in  severe  cases  all  may  be  swollen  and  infiltrated. 
The  spleen  is  affected  in  a  similar  manner.  When  the  hyperemia  be- 
gins in  the  intestines  the  spleen  enlarges,  and  by  the  end  of  the  first 
week  the  enlargement  is  sufficient  to  be  recognized  through  the  abdom- 
inal wall,  and  at  the  maximum  the  organ  is  two  or  three  times  larger 
than  normal.  The  change  consists  in  a  multijjlication  of  the  cellular 
elements,  which  at  first  increases  the  firmness  of  the  organ,  but  ulti- 
mately it  becomes  exceedingly  soft,  so  that  it  almost  falls  to  pieces  by 
its  weight.  The  retrogression  occurring  in  the  spleen  consists  of  a 
degeneration  and  disappearance  of  the  new  elements  ;  the  capsule  con- 
tracts, the  trabeculse  become  more  firm,  and  the  pulp  more  compact. 
The  lesions  thus  far  considered  are  peculiar  to  typhoid.     We  have 


TYPHOID  FEVER.  g93 

now  to  discuss  changes  due  to  a  persistent  elevation  of  the  tempera- 
ture, and  known  under  the  designation  of  parenchymatous  degenera- 
tion of  organs — the  liver,  kidneys,  muscular  tissue  of  the  heart,  the 
nervous  system,  and  muscular  system  of  animal  life  in  general.  Par- 
enchymatous degeneration  is  a  granular  and  fatty  change  affecting 
the  proper  gland  elements.  In  the  liver  the  cells  become  clouded 
with  fat-granules  and  the  nuclei  disappear,  and  when  the  change  is 
most  advanced  they  break  down  into  granular  fragments.  The  effect 
of  this  process  is  to  diminish  the  firmness  and  consistency  of  the  organ, 
to  change  its  color  to  a  grayish  or  yellowish-red,  and  to  materially 
diminish  the  blood  in  the  small  vessels.  The  degree  of  the  change 
varies  chiefly  in  accordance  with  the  range  of  temperature  ;  it  may  be 
very  slight  or  very  considerable,  and  the  right  lobe  is  usually  further 
advanced  in  the  change  than  the  left.  In  the  kidneys  the  epithelium 
of  the  tubes,  first  of  the  cortex,  then  of  the  pyramids,  becomes  gran- 
ular, cloudy,  and  the  contour  indistinct,  the  nuclei  disappearing,  and 
at  last  breaks  down  into  granular  fragments.  The  effect  of  these  lesions 
is  to  diminish  the  firmness  of  the  organs,  and  to  change  their  color. 
In  the  kidney,  as  in  the  liver,  the  amount  of  the  change  varies,  and  is 
determined  by  the  range  of  temperature.  Albuminuria  results  when 
the  alteration  is  at  all  extensive.  Yery  important  are  the  changes 
occurring  in  the  cardiac  muscle.  The  granules  appear  in  large  num- 
bers, arranged  in  parallel  rows,  filling  the  fibers,  and  ultimately  caus- 
ing a  disappearance  of  the  striae.  The  result  of  this  change  is  very 
injurious.  The  tissue  of  the  heart  is  soft,  flabby,  and  easily  torn,  and 
the  organ  in  advanced  cases  can  not  maintain  its  shape  when  laid  on  a 
table,  but  flattens  out  like  so  much  mush.  In  the  muscles  the  degen- 
eration takes  the  two  forms  of  granular  and  waxy.  In  the  brain  the 
changes  due  to  parenchymatous  degeneration  have  not  been,  as  yet, 
adequately  studied,  but  the  naked-eye  alterations  are  very  definite, 
the  chief  change  consisting  in  anaemia,  oedema  of  the  brain,  the  sub- 
arachnoid spaces,  the  perivascular  lymph-spaces,  and  the  ventricles 
containing  a  good  deal  of  fluid.  Some  parts  of  the  brain  are  less  firm 
than  normal,  and  more  or  less  atrophy  occurs,  the  convolutions  flatten- 
ing and  the  ventricles  enlarging,  etc.  Rarely  the  lesions  of  an  acute 
meningitis  are  superadded  to  those  of  typhoid.  In  the  respiratory 
organs  there  are  various  lesions,  which,  if  not  essential  to  typhoid,  are 
at  least  usually  associated  with  those  that  are  peculiar.  Not  unfre- 
quently  the  larynx  is  attacked  with  ulceration  ;  but  the  most  charac- 
teristic change  is  that  of  catarrh  of  the  bronchial  mucous  membrane, 
which  is  swollen,  deeply  injected,  and  coated  with  viscid  mucus.  The 
access  of  air  being  cut  off  from  some  of  the  vesicles,  they  collapse,  or 
pass  into  the  state  of  atelectasis.  The  dependent  portions  of  the  lungs 
are  in  the  condition  of  hypostasis,  with  or  without  oedema,  and  in  rare 
cases  lobar  or  lobular  pneumonia. 


694  FEVERS. 

Symptoms. — As  a  rule,  a  prodromic  period  ushers  in  a  case  of 
typhoid.  For  a  week  or  ten  days,  or  even  longer,  a  lack  of  the  usual 
vigor  and  a  disposition  to  tire  easily  are  perceived.  Headache,  epis- 
taxis,  tinnitus  aurium,  a  poor  appetite,  and  a  slight  diarrhoea,  are  also 
noted.  The  mind  is  dull,  and  mental  application  is  very  fatiguing  ; 
sleep  is  disturbed  by  dreams  and  is  unrefreshing.  Presently  some 
chilliness  is  felt  at  different  times  and  for  several  days,  and  the  fever 
begins  ;  the  strength  is  exhausted,  and  the  patient  betakes  himself  to 
bed.  In  other  cases,  the  prodromic  period  is  characterized  by  the 
development  of  an  acute  catarrh  of  the  stomach  ;  there  are  disgust 
for  food,  nausea,  and  a  heavily  coated  tongue  ;  temporary  relief  is 
afforded  by  spontaneous  or  contrived  vomiting,  but  the  symptoms  are 
soon  resumed,  the  nausea  continues,  some  diarrhcea  occurs,  great  weak- 
ness is  felt,  headache,  hebetude  of  mind,  and  disturbed  sleep  are  ex- 
perienced, and  gradually  the  fever  lights  up.  In  still  other  cases — and 
they  are  relatively  very  numerous  in  the  malarial  regions  of  this  coun- 
try— an  attack,  apparently  of  intermittent  fever,  precedes  the  fever 
proper  ;  there  may  be  several  distinct  paroxysms,  but  the  fever  soon 
assumes  the  remittent  type,  and  the  phenomena  of  typhoid  gradually 
develop.  A  few  cases  begin  without  any  prodromes.  A  person,  ap- 
parently in  full  health,  is  unexpectedly  seized  with  some  chilliness, 
followed  by  fever,  languor,  headache,  etc.  On  the  next  day  there  is 
more  chilliness,  the  fever  is  more  pronounced,  the  mind  is  already  be- 
coming dull,  and  the  other  symptoms  of  typhoid  come  on  immediately. 
The  disease  is  held  to  originate  with  the  first  chilliness  or  the  first 
elevation  of  temperature,  and  from  these  data  is  computed  the  dura- 
tion of  the  different  periods.  As  the  appearance  of  fever  marks  the 
onset  of  the  disease,  so  its  decline  and  disapjiearance  establish  con- 
valescence. 

First  Week. — The  symptoms  of  the  prodromic  period  are  more 
pronounced  :  there  are  violent  headache,  a  sense  of  confusion  and 
mental  weakness  ;  singing  and  drumming  in  the  ears  ;  some  bleeding 
at  the  nose,  often  but  a  few  drops  escaping  ;  the  eyes  are  intolerant 
of  light,  the  ears  of  sound  ;  the  patient  may  still  get  on  and  off  the 
bed,  but,  when  he  attempts  to  stand  erect,  his  limbs  tremble,  and  he  is 
seized  with  vertigo.  The  appetite  is  gone  and  the  suggestion  of  food 
is  repugnant ;  there  is  a  bad  taste  in  the  mouth,  and  the  thirst  is  ex- 
cessive. The  tongue  is  at  first  large,  pale,  indented  at  the  margins 
with  the  teeth,  but  it  becomes  dry  and  smaller  by  the  fifth  day  ;  the 
coating  peels  off  with  the  epithelium  in  patches,  leaving  a  very  red, 
dry,  and  glazed  surface,  and  it  is  also  somewhat  tremulous.  Some 
■diarrhoea  may  have  existed  during  the  prodromic  period,  and  there  is 
often  a  tendency  to  constipation  dui'ing  the  first  week,  but,  when  this 
is  the  case,  it  is  found  that  a  light  purgative  acts  with  unwonted  vio- 
lence.    More  or  less  diarrhoea  exists  durinsr  the  first  week.     At  first 


TYPHOID  FEVER.  695 

the  stools  consist  of  thin,  brownish  fseces,  having  a  rather  strong  odor, 
but  they  increase  daily  in  number  and  change  in  character  toward  the 
end  of  the  second  week,  when  they  assume  the  yellow,  ochre  color,  the 
well-known  "  pea-soup  "  appearance.  When  they  are  permitted  to 
stand,  they  separate  into  two  distinct  strata :  the  upper  one  liquid, 
holding  salts,  extractives  containing  bile,  epithelium,  ammoniaco-mag- 
nesian  phosphate,  and  fat,  finely  emulsionized  ;  the  lower  one,  more 
consistent,  containing  analogous  ingredients  to  those  in  the  upper 
layer,  but,  in  addition,  a  quantity  of  soft,  yellow  concretions  made  up 
of  fat,  albumen,  pigments,  and  phosphates  (Jaccoud).  Great  interest 
attaches  to  the  microscopic  examination  of  the  stools,  since  it  is  gen- 
erally conceded  that  the  typhoid  matter  exists  in  the  stools,  but  the 
results  thus  far  attained  must  be  regarded  as  rather  negative,  although 
great  numbers  of  micrococci,  of  a  brownish-yellow  color,  and  small 
bodies  belonging  to  the  penicillium  group,  have  been  discovered,  but 
they  are  so  often  present  in  benign  liquids  that  a  pathological  im- 
portance can  hardly  be  assigned  them.*  Gurgling  in  the  right  ileo- 
csecal  region  has  been  classed  among  the  symptoms  of  this  period,  but, 
as  it  is  present  in  diarrhoeal  affections,  there  is  no  great  value  to  be  at- 
tached to  it  alone.  Tenderness,  as  well  as  gurgling,  makes  a  more 
significant  impression,  especially  if,  as  there  ought  to  be,  ait  the  end  of 
the  first  week,  some  fullness,  even  distention  of  the  abdomen.  At  this 
time  distinct  increase  in  the  area  of  splenic  dullness  can  be  made  out, 
and  the  enlarged  spleen  may  be  often  felt.  Enlargement  of  the  tonsils, 
follicles  of  the  pharynx,  and  of  the  large  follicles  at  the  base  of  the 
tongue  takes  place  coincidently  with  the  development  of  the  intestinal 
glandular  appendages.  Catarrh  of  the  bronchial  tubes,  shown  by  some 
dry  and  moist  rales  over  the  dependent  portions  of  the  lungs  especially, 
comes  on  at  this  time,  but  its  intensity  vai'ies  in  different  epidemics 
and  in  different  individuals.  At  the  end  of  the  first,  or  at  the  beginning 
of  the  second  week,  appear  the  very  characteristic  disorders  of  the  ner- 
vous system.  The  restlessness,  the  complaints  about  the  aching  in  the 
back  and  limbs  cease,  and  instead  there  is  a  condition  of  apathy  and  in- 
difference. The  patient  becomes  somnolent,  but  is  easily  aroused,  and 
does  not  sleep  well  at  night.  Some  of  his  indifference  and  stupidity  of 
expi-ession  is  due  to  dullness  of  hearing,  and  hence  he  must  be  spoken 
to  somewhat  loudly.  When  roused  he  responds  correctly,  and  expresses 
himself  as  feeling  very  well.  From  the  seventh  to  the  tenth  day  some 
disturbance  of  mind  is  noted  ;  it  may  be  toward  evening,  or  at  night 
only,  or  when  roused,  and  ordinarily  it  is  nothing  more  than  a  tranquil 
muttering,  or,  as  it  is  commonly  expressed,  "  low-muttering  delirium." 
Sometimes  the  delirium  takes  a  more  active  character  :  it  is  wild,  furious 

*  To  this  statement  must  be  excepted  the  recent  discovery  of  Klebs,  "  Der  Ileoty- 
phus  cine  Schistomycose,"  "  Archiv  f Ur  experimentelle  Pathologic  und  Pharmacologie." 
Zwolften  Bandes,  s.  231.     He  gives  the  results  of  examination  of  twenty-four  cases. 


696  FEVERS. 

and  ungovernable  ;  the  patient  gets  out  of  bed,  resists  the  attempts  to 
feed  him,  spits  his  drink  or  medicine  into  the  face  of  his  nurse  ;  will 
not  keep  any  covering  on  him,  talks  incessantly,  and  not  only  gets  out 
of  bed,  but  will  jump  out  of  the  window.  This  condition  of  wild 
delirium  coincides  with  greatly  elevated  temperature,  rapid  pulse,  and 
the  other  evidences  of  extreme  illness.  Fortunately,  these  cases  are 
rare.  Usually  the  delirium  is  a  low  monotone,  mumbling  incoherent- 
ly, and  is  accompanied  by  picking  at  imaginary  objects  on  the  bed- 
clothes, and  subsultus  tendinum.  The  trembling  of  the  muscles  is 
seen  not  only  in  the  subsultus  of  the  tendons  of  the  forearms,  but  in 
the  protrusion  of  the  tongue.  If  not  too  far  gone  in  stupor,  the  pa- 
tient may  yet  protrude  his  tongue  when  urged  to  do  so,  but  he  does  it 
slowly,  hesitatingly,  with  much  trembling,  and  he  forgets  to  return  it 
again,  keeping  it  protruded  until  forced  to  return  it.  The  urine  is 
acid  in  reaction,  is  rich  in  urea,  urates  and  extractives,  and  poor  in 
chlorides.  The  urine  frequently  contains  the  urinary  indigo,  leucin 
and  tyrosin,  and  in  many  cases  albumen.  At  the  end  of  the  first 
week,  or  at  the  beginning  of  the  second  week,  an  eruption  of  roseola 
appears,  in  the  form  of  small,  isolated,  lenticular  spots,  about  the  size 
of  a  pin's-head,  disappearing  on  pressure,  to  quickly  reappear  when  the 
pressure  is '  removed.  They  vary  greatly  in  number,  often  from  five 
to  twenty,  scattered  over  the  lower  thorax  and  abdomen.  They  may 
be  much  more  numerous,  several  hundred  in  number,  and  may  be  dis- 
tributed generally  over  the  body.  They  may  be,  and  indeed  often 
are,  entirely  absent,  especially  in  the  milder  cases.  It  occasionally 
happens  that  a  larger,  darker  eruption,  of  a  pigmentary  character, 
appears  before  or  with  the  roseola,  but  these  have  no  special  impor- 
tance. When  there  has  been  much  sweating,  an  abundant  crop  of 
miliary  vesicles  known  as  "  sudamina  "  may  appear  on  the  neck,  chest, 
and  elsewhere.  With  the  close  of  the  second  and  the  beginning  of 
the  third  week,  the  typhoid  symptoms  develop  in  intensity.  The 
stupor  increases,  so  that  the  patient  can  hardly  be  roused,  and  is  indif- 
ferent to  all  about  him.  If  liquids  are  placed  in  the  mouth,  they  are 
slowly  swallowed.  The  patient  lies  on  his  back,  his  eyes  partly  closed, 
mouth  open  and  black  with  accumulated  sordes,  his  face  is  sunken, 
dusky,  with  a  faint,  reddish  tinge  in  the  center,  the  lips,  now  and  then 
moving  with  an  unintelligible  muttering,  are  dry  and  cracked,  and  his 
strength  is  so  far  exhausted  that  he  can  not  keep  his  position,  but  sinks 
toward  the  foot  of  the  bed.  The  faeces  and  urine  may  be  passed  invol- 
untarily, or  the  urine  may  be  retained  and  dribble  away,  the  bladder 
becoming  enormously  distended.  The  pulse  continues  frequent,  from 
90  to  120,  or  higher,  but  its  force  declines.  The  impulse  of  the.  heart 
is  feeble,  and  hence  a  tendency  to  stasis  in  the  lungs  and  brain  ex- 
ists. The  pulse  is  compressible,  and  its  tension  so  low  that  it  has  a 
double  beat  (dicrotic  pulse).    The  fever  of  typhoid,  although  called  con- 


TYPHOID   FEVER. 


697 


tinuous,  is  not  so  ;  it  has  a  distinctly 


Fig.  45.— Temperature  in  Typhoid  Fever. 


remittent  type.     For  the  first 
week   there   is   a   gradual   as- 
cension,   and,    although  there 
is   a   morning    remission    and 
an  evening  exacerbation,  each 
exacerbation  is  a  little  higher 
than  the  preceding,  until  the 
maximum  is  reached.     During 
the  second  week  the  fever  is 
continuous  ;  during  the  third 
it  begins  to  be  remittent,  and, 
during  the  fourth,  intermittent, 
the  daily  exacerbations  lessen- 
ing regularly  until  the  normal 
is  reached.     The  fever  at  its 
maximum    is    continuous,   be- 
cause the  daily  remissions  cor- 
respond to   the   morning   and 
evening  variations  of  the  daily 
temperature  in  health.     With 
the   remissions   at  the  end  of 
the  third  week,  there  are  evi- 
dences of  a  change  for  the  bet- 
ter in  favorable  cases.     Dur- 
ing the  third  week,  however, 
chiefly  occur  the  complications 
which  exercise  so  unfavorable 
an  influence  over  the  progress 
of  the  disease,  but  these  are  re- 
served for  separate  considera- 
tion.    In  the  fourth  week  the 
patient   is  well  aroused  from 
the   stupor,  and  is  fully  con- 
scious  of   his    condition.     In- 
stead of  indifference,  he  is  full 
of   complaints.       His    eye    is 
brighter,  and  the  face,  though 
emaciated,  begins  to  have  ex- 
pression again.     The  delirium 
ceases,  the  nights  are  less  dis- 
turbed, and,  instead  of  somno- 
lence,  the   sleep  although   re- 
freshing  is   interspersed   with 
periods  of  wakefulness.      The 
tongue   and   gums    clean,    the 


698  FEVERS. 

appetite  returns  ;  the  diarrhoea  ceases,  and  is  replaced  by  constipation  ; 
the  flatulent  distention  of  the  abdomen  subsides  ;  the  spleen  shrinks  ; 
the  urine  becomes  more  abundant  and  limpid,  and  there  are  copious 
perspirations  for  several  days,  occurring  especially  during  sleep. 

Course,  Duration,  and  Termination. — The  course  of  the  fever  as 
described  is  the  usual  one  of  a  perfectly  developed  case.  But  there 
are  many  variations  due  to  individual  peculiarities,  to  surrounding  in- 
fluences, to  complications  which  may  be  most  conveniently  studied 
under  this  head.  The  principal  cause  of  a  fatal  termination  is  the 
prolonged  high  temperature,  and  hence,  in  any  prognostic  estimate, 
this  must  be  considered.  Thus  Liebermeister  shows  that,  when  the 
temperature  was  under  104°  Fahr.,  the  percentage  of  mortality  was 
9*6  ;  if  the  temperature  reached  and  passed  104°,  the  mortality  was 
29"1  ;  if  the  temperature  rose  to  105*8°  or  over,  the  mortality  was 
greater  than  one  half.  Next  to  the  height  is  the  duration  of  the 
fever  ;  and,  consequently,  the  longer  the  maximum  of  the  fever  is 
maintained,  the  greater  the  mortality.  The  point  to  which  the  fever 
attains  at  the  end  of  the  first  week,  as  a  rule,  indicates  the  range  of 
temperature  to  occur,  for  in  uncomplicated  cases  it  is  then  at  the 
maximum.  Furthermore,  the  greater  the  daily  fluctuations  of  the 
fever,  the  less  severe  it  will  prove.  Treatment  has  exercised  great  in- 
fluence on  the  mortality,  esj)ecially  treatment  based  on  a  recognition 
of  the  importance  of  reducing  the  temperature.  Age  has  a  great  in- 
fluence over  the  termination  of  typhoid — in  the  young  the  mortality 
is  proportionally  less  ;  in  the  aged  proportionally  greater.  The  indi- 
vidual constitution  has  an  undoubted  effect  in  increasing  or  diminish- 
ing the  mortality  ;  the  nervous  and  excitable  bear  the  disease  poorly, 
and  the  phlegmatic  better ;  the  lean  and  muscular  also  endure  the 
strain  of  the  disease  better  than  the  fat.  But  the  habitual  indulgence 
in  spirits  has  a  more  unfavorable  influence  than  any  of  the  conditions 
named.  In  every  epidemic  there  are  many  cases  of  much  milder  type, 
and  there  are  also  irregular  and  abortive  forms.  In  the  milder  cases, 
the  temperature  rarely  exceeds  103°  in  the  axilla  ;  there  is  no  delirium, 
only  confusion  of  mind  on  awaking  from  sleep,  and  hebetude  of  mind  ; 
the  diaiThoea  is  slight,  and  the  different  periods  are  short,  so  that  the 
whole  duration  may  be  comprehended  in  twenty-one  days.  Those  are 
regarded  as  abortive  in  which  there  ai'e  no  prodromes,  the  symptoms 
begin  abruptly,  often  with  a  distinct  rigor,  the  temperature  rising  in  a 
day  or  two  to  the  maximum  of  104°  Fahr.,  and,  without  the  weeks  of 
continued  fever,  assuming  the  remittent  and  intermittent  form  of  the 
fourth  week  at  the  end  of  the  first,  and  terminating  within  two  weeks. 
While  the  mild  form  is  extremely  common  in  this  country,  the  abor- 
tive forms,  according  to  the  author's  observation,  are  infrequent. 
The  course,  duration,  and  termination  of  typhoid  are  much  influenced 
by  the  complications.     Haemorrhage  of  the  intestines  is  one  of  the 


TYPHOID  FEVER.  699 

most  important.  This  takes  place  at  various  times  in  the  course  of 
the  fever,  and  the  quantity  of  blood  lost  is  very  different  in  different 
cases.  The  blood  may  be  pure,  partly  fluid  and  coagulated,  or  black- 
ish, or  converted  into  a  tar-like  mass.  The  second  week  is  the  most 
usual  period  for  the  haemorrhage  ;  next,  the  third  week  ;  but  it  may 
occur  at  any  period.  The  proportion  of  cases  of  haemorrhage  to  the 
whole  number  is  about  five  per  cent.  When  it  occurs  during  the  first 
week,  it  is  a  result  of  the  increased  pressure  in  the  intestinal  vessels — 
a  necessary  product  of  hypersemia  ;  if  it  occur  in  the  second  and  third 
weeks,  it  is  caused  by  the  sloughs,  a  vessel  being  laid  open  by  their 
detachment ;  if  later,  vessels  are  eroded  by  the  spread  of  ulceration. 
Any  considerable  haemorrhage,  if  no  part  escape  externally,  is  an- 
nounced by  sudden  depression,  coldness  of  the  surface,  pallor,  faint- 
ness,  weakness  of  the  pulse,  lowering  of  the  temperature.  Unless  re- 
peated, the  effect  of  the  haemori'hage  subsides  in  a  day  or  two,  the 
pulse  rises,  the  delirium  and  stupor,  which  may  have  been  lessened  by 
it,  assume  their  former  characteristics.  The  more  severe  the  haemor- 
rhage, the  more  injurious.  The  notion  has  been  entertained  by  some 
that  a  considerable  haemorrhage  might  have  a  favorable  influence  over 
the  progress  of  a  case,  but  the  statistics  are  opposed  to  such  an  opin- 
ion, those  of  Liebermeister,  for  example,  showing  that  the  mortality 
is  three  times  greater  in  those  having  this  complication,  but  statis- 
tics on  this  point  are  not  altogether  conclusive,  since  usually  those 
are  the  most  severe  cases,  in  other  respects,  in  which  haemorrhage  oc- 
curs. The  introduction  of  hydrotherapy  has  in  Germany  diminished 
the  frequency  of  intestinal  haemorrhage  as  a  complication  of  typhoid. 

Perforation,  as  a  cause  of  death,  occurs  in  from  five  to  fifteen  per 
cent.  The  period  is  from  the  third  to  the  fifth  week,  although  it  may 
occur  as  early  as  the  first,  and  is  due  to  the  extension  of  ulceration,  the 
opening  in  the  peritoneum  being  made  at  last  by  some  hardened  faeces, 
undigested  food,  sudden  distention  of  the  bowel  by  gas,  and,  it  may 
be,  by  ascarides,  which  are  often  found  in  the  peritoneal  cavity  after- 
ward. The  shape  of  the  ulcer  is  an  inverted  cone,  the  opening  in  the 
peritoneum,  the  apex,  having  the  size  of  a  pin-head  to  a  small  pea. 
The  ilium  is  the  part  usually  perforated,  but  the  ulcer  may  be  situated 
high  up  in  the  small  intestine,  or  it  may  be  in  the  colon,  especially  the 
appendix  vermiformis.  Very  often  it  is  the  ulcer  of  a  solitary  gland. 
Although  the  more  extensive  the  ulcerations  the  greater  the  danger 
of  perforation,  yet  it  has  happened  that  a  single  ulcer  has  opened  the 
peritoneum.  The  immediate  result  of  the  perforation  is  shock.  The 
surface  grows  cold,  the  temperature  falls  several  degrees,  the  pulse 
becomes  excessively  feeble,  and  death  may  ensue  in  a  condition  of 
extreme  exhaustion.  Usually,  however,  the  patient  rallies,  reaction 
ensues,  and  acute  peritonitis  rapidily  develops.  It  sometimes  happens, 
when  the  rupture  may  be  produced  by  accumulation  of  gas,  that  the 


700  FEVERS. 

abdominal  cavity  is  greatly  distended  by  it,  the  epigastrium  rendered 
prominent,  and  the  diaphragm  pushed  up,  impeding  respiration.  At 
the  moment  rupture  takes  place,  intense  pain  is  experienced,  beginning 
in  the  right  inguinal  region,  and  radiating  thence  over  the  abdomen. 
The  temperature  rises  again,  after  some  preliminary '  chills,  and  the 
phenomena  of  peritonitis  are  added  to  the  ordinary  symptoms.  Re- 
covery very  rarely  takes  place,  and  death  occurs  usually  within  four 
days  after  the  perforation,  unless,  indeed,  the  first  shock  of  the  acci- 
dent paralyzes  the  heart.  In  a  few  cases,  with  profound  coma,  per- 
foration has  occurred  without  causing  any  objective  evidences  of  the 
complication.  Perforation  is  much  more  apt  to  occur  in  men  than  in 
women.  Peritonitis  may  be  due  to  other  causes  than  perforation — ^by 
the  extension  of  ulceration  to  the  peritoneum,  by  rupture  of  the  gall- 
bladder, rupture  of  the  spleen,  etc.  The  author  has  met  with  a  fatal 
case  of  rupture  of  the  spleen,  occurring  during  convalescence,  and 
caused  by  a  not  violent  blow  on  the  side.  Examination  of  the  splenic 
region  should  be  made  with  care  after  the  second  week,  because  of  the 
ease  with  which  the  spleen  may  be  ruptured.  The  chief  complication 
on  the  part  of  the  circulatory  organs  is  granular  degeneration  of  the 
heart-muscle  already  described,  thromboses  from  cardiac  weakness, 
forming  in  the  heart  or  in  tiie  great  vessels.  In  the  respiratory  system 
there  are  various  changes,  some  of  them  of  great  importance.  Epistaxis 
and  bronchitis  have  been  already  mentioned  as  symptoms  of  the  dis- 
ease proper,  so  constant  are  they  in  appearing.  Diphtheritic  exudations 
in  the  fauces  and  ulcers  of  the  larynx,  due  to  diphtheritic  infiltration 
of  the  mucous  membrane,  are  occasional  and  very  important  complica- 
tions. Death  is  sometimes  unexpectedly  due  to  oedema  of  the  glottis, 
and  this  may  be  produced  by  a  laryngeal  ulcer.  Atelectasis,  hypostatic 
congestion,  splenization,  hsemorrhagic  infarctions,  and  oedema,  are  all 
complications  arising  in  the  lungs  from  feebleness  of  the  heart's  action. 
Caseous  pneumonia,  pleurisy,  and  acute  miliary  tuberculosis  are  se- 
quelae, sometimes  the  outcome  of  the  above-mentioned  diseases  due  to 
stasis.  (Edema  of  the  brain  is  a  frequent  condition,  which  seems  a 
necessary  part  of  the  morbid  anatomy  of  typhoid.  Besides  this,  there 
are  various  complications  growing  out  of  the  changed  state  of  the  sol- 
ids and  fluids.  Cerebral  haemorrhage  and  acute  meningitis  are  very 
rare.  Derangements  of  the  mental  faculties  are  by  no  means  uncom- 
mon, and  are  due  to  the  ansemia  and  the  functional  torpor  of  the  gray 
matter.  The  derangement  may  assume  the  form  of  exaltation,  or  of 
depression  and  melancholy.  When  an  hereditary  tendency  exists,  the 
case  assumes  a  higher  degree  of  importance,  those  due  merely  to  the 
condition  of  the  brain,  the  result  of  the  typhoid  disease,  recovering 
with  less  or  greater  promptitude.  The  condition  of  the  kidneys  which 
occurs  in  many  cases,  represented  objectively  by  a  trace  of  albumen 
in  the  urine,  passes  into  well-developed  Bright's  disease  in  a  small  pro- 


TYPHOID   FEVER.  701 

portion  of  them.  These  go  through  the  usual  course,  and  terminate 
in  recovery.  Hsemorrhagic  infarction  occurs  in  a  few  cases.  The 
menses  frequently  appear  during  the  course  of  typhoid,  and  exercise  a 
rather  favorable  influence  over  the  course  of  the  disease.  Abortion  is 
apt  to  occur,  and  of  course  adds  to  the  gravity  of  the  situation.  On 
the  part  of  the  skin,  the  most  important  complication  is  that  of  bed- 
sores. The  parts  subjected  to  pressure  are  those  which  slough — the 
sacrum,  nates,  great  trochanters,  and  the  crest  of  the  ilium.  In  some 
subjects,  so  depraved  is  the  condition  of  the  solids,  that  any  part  sub- 
jected to  pressure  sloughs.  The  depth  and  extent  of  the  sloughing 
vary  from  redness,  inflammation,  and  abrasion  of  the  skin,  to  destruc- 
tion of  the  skin,  fascia,  and  muscles,  extending  to  the  periosteum.  The 
effect  of  this  complication  depends  on  the  extent  of  the  injury  done. 
When  there  is  considerable  sloughing,  suppuration,  and  decomposition, 
fever  will  be  excited,  and  systemic  infection,  septicaemia,  and  pyae- 
mia result.  Falling  out  of  the  hair  and  arrest  of  the  growth  of  the 
nails  are  usual  complications. 

Relapses. — Increased  fever,  due  to  some  complication,  may  be  con- 
founded with  a  genuine  relapse,  but  the  latter  pui'sues  the  ordinary 
course  of  the  fever,  except  that  it  is  more  rapid  in  its  course  and 
shorter  in  its  duration.  There  occurs  in  the  relapse  a  similar  range  of 
temperature,  the  spleen  enlarges,  roseola  appears,  and  the  other  symp- 
toms in  their  order  come  on.  Of  itself  the  relapse  is  milder,  but  the 
subject  enduring  it  is  enfeebled  by  an  illness,  so  that  the  danger  must 
be  regarded  as  greater.  The  number  of  cases  undergoing  relapse 
varies  fi'om  six  to  twelve  per  cent. 

Treatment. — Although  for  typhoid,  a  specific  disease,  we  have  no 
specific  remedy,  a  treatment  has  originated  in  Germany  which  is 
known  as  the  specific  treatment.  Mercury  and  iodine  are  the  specific 
remedies.  There  is  no  doubt,  if  statistics  may  be  depended  on,  that 
calomel,  in  large  doses  during  the  first  week,  favorably  modifies  the 
disease.  Ten  grains  in  a  single  dose,  on  alternate  days,  is  about  the 
average  of  the  quantity  given  by  various  therapeutists.  If  the  tem- 
perature is  high,  it  may  be  given  on  successive  days,  but  the  danger 
of  inducing  salivation  is  great,  when  it  is  administered  at  short  inter- 
vals. The  effect  of  the  mercurial  treatment  is  to  lower  the  tempera- 
ture, to  diminish  the  severity,  and  apparently  lessen  the  duration  of 
the  case.  The  treatment  by  iodine  consists  in  the  administration  of 
Lugol's  solution — from  three  to  five  minims  in  water  three  times  a 
day,  and  continued  during  the  first  two  weeks  certainly,  and  probably 
up  to  the  beginning  of  convalescence.  Taking  the  figures  of  Lieber- 
meister  for  illustration,  they  show  that  while  the  mortality  under 
ordinary  treatment  reached  13'2,  under  calomel  it  was  8'8,  and  under 
iodine  10-9.  The  author's  experience,  which  is  not  yet  sufficiently 
large  for  decision  of  the  question,  is  in  accord  with  the  conclusions  of 


702  FEVERS. 


» 


Liebermeister.  He  has  used,  with  apparently  decided  success,  the  com- 
bination of  iodine  and  carbolic  acid  (1^.  Tinct.  iodinii  3  ij,  acid,  car- 
bolic. 3  j.  M.  Sig.  One  to  three  drops  three  times  a  day).  Xitrate  of 
silver,  sulphate  of  copper,  arsenic,  and  turpentine,  each  has  an  advocate 
of  its  usefulness — all  being  directed  against  the  intestinal  complication 
or  lesion.  As,  however,  the  main  point  in  the  management  of  typhoid 
is  to  depress  the  temperature,  the  treatment  directed  to  that  end  is  the 
most  important.  The  antipyretics  available  for  this  purpose  are  hy- 
drotherapy, quinia,  and  digitalis.  The  method  of  hydrotherapy  con- 
sists in  immersion  in  water  at  a  certain  temperature,  the  wet  pack,  and 
local  abstraction  of  heat  by  sj)ecial  appliances.  As  private  houses  are 
unprovided  with  the  means  of  administering  baths  to  fever-patients, 
this  method  can  be  utilized  only  in  hospitals.  The  method  of  gradual 
reduction  of  heat  we  hold  to  be  preferable.  The  patient  is  put  in  the 
water  at  98°,  and  then  by  the  addition  of  cold  water  the  temperature 
of  the  bath  is  brought  down  to  60°  Fahr.  The  thermometer  must  be 
constantly  in  position  to  observe  the  effect,  and  the  duration  of  the 
bath  ought  not  to  exceed  ten  to  fifteen  minutes.  The  temperatm'e  re- 
quiring the  bath  is  at  any  point  above  102"5°  (axillary),  and  the  repe- 
tition of  it  is  determined  by  the  effect — every  two  to  every  six  hours, 
night  as  well  as  day,  may  be  regarded  as  usual.  If  the  patient  is 
made  faint  or  depressed,  some  stimulant  should  be  given  before,  dur- 
ing, or  subsequent  to  the  bath,  according  to  the  result.  If  the  bath  is 
impracticable,  the  wet  pack  may  be  used  with  equal  effect.  The  bed 
is  protected  by  a  gum  cloth  ;  a  sheet  is  wrung  out  of  cold  water  ;  the 
patient  is  thoroughly  wrapped  in  it,  and  then  covered  up  with  blank- 
ets for  a  few  minutes,  when  the  process  is  renewed  if  necessary.  The 
same  rules  hold  good  with  regard  to  the  repetition  and  management 
of  the  pack,  as  of  the  bath,  and  the  results  achieved  are  equally  bene- 
ficial. The  temperature  of  the  body  may  also  be  reduced  by  ice-bags 
applied  to  the  abdomen,  and  by  ice- water  injections  in  the  rectum,  but 
these  can  not  be  utilized  in  typhoid.  There  are  several  contraindica- 
tions to  the  use  of  cold  baths.  The  first  and  most  important  is  haemor- 
rhage from  the  intestines,  the  next  is  great  weakness  of  the  heart's 
action,  and  the  third  is  coldness  of  the  surface  with  high  internal  heat. 
Next  to  hydrotherapy,  and  probably  superior  as  a  remedy  for  reducing 
abnormal  temperature  of  the  body,  is  quinine.  ISTotwithstanding  the 
good  results  which  have  been  obtained  from  baths,  it  is  probable  that 
quinia  will  always  be  preferred  by  many,  because  of  the  readiness 
with  which  it  may  be  brought  to  bear  on  the  production  of  heat.  In- 
deed, Liebermeister,  a  strong  advocate  for  hydrotherapy,  says,  if  he 
"  were  forced  to  the  unpleasant  alternative  of  adopting  only  one  or  the 
other  of  these  two  means — cold  water  or  quinia — I  should,  in  the  ma- 
jority of  cases,  choose  the  latter."  To  reduce  the  abnormal  tempera- 
ture, antipyretic  doses  are  required,  from  twenty  to  forty  grains.     A 


TYPHOID   FEVER.  ^03 

decline  of  several  degrees,  and  lasting  a  number  of  hours,  will  be  caused 
by  a  sufficient  dose,  and  a  less  effect  than  this  will  not  justify  the  em- 
ployment of  the  remedy.  It  is  a  good  plan  to  prescribe  a  scruple 
every  four  hours,  until  a  decided  reduction  of  temperature  takes  place, 
then  its  use  should  be  suspended  until  the  temperature  begins  to  rise 
again.  The  power  of  quinia  to  reduce  abnormal  heat  may  be  aided  by 
digitalis,  when  the  former  is  inadequate.  It  is  best  to  prescribe  a  table- 
spoonful  of  the  officinal  infusion  every  four  hours  for  the  period  of 
twenty-four  hours,  when  some  antipyretic  doses  of  quinia  should  be 
given.  This  combination  will  prove  effective,  but  the  objections  to 
the  administration  of  digitalis  may  be  very  strong.  If  the  stomach  is 
irritable  and  the  action  of  the  heart  feeble,  digitalis  must  be  with- 
held. The  best  results  are  obtained  from  a  combination  of  the  anti- 
pyretics— the  use  of  baths  or  packs,  and  of  quinine  and  digitalis.  The 
recognition  of  the  important  part  played  by  high  temperature  in  the 
ravages  of  typhoid  and  the  influence  of  antipyretics  in  controlling 
these  ravages  have  put  a  different  expression  on  the  face  of  typhoid 
statistics. 

If,  in  the  treatment  of  typhoid,  the  temperature  be  kept  within 
proper  limits,  there  will  be  less  and  less  need  for  attention  to  compli- 
cations. Nevertheless,  we  must  be  prepared  to  obviate  the  tendency 
to  death,  and  to  correct  complications.  Failure  of  the  heart  requires 
stimulants,  but  otherwise  stimulants  should  not  be  given  in  typhoid,  ex- 
cept in  the  case  of  those  addicted  to  their  use,  who  require  a  regulated 
daily  amount.  Restlessness  and  prolonged  wakefulness  are  as  a  rule 
most  successfully  relieved  by  morphia  and  belladonna.  Chloral  must 
be  used  with  caution,  because  of  the  weakness  of  the  heart-muscle.  If 
the  tongue  is  dry,  if  there  is  great  thirst,  and  the  abdomen  is  much  dis- 
tended with  gas,  turpentine  is  highly  useful.  Muriatic  acid,  also,  acts 
well  under  the  same  circumstances.  If  the  bowels  act  too  freely,  ni- 
trate of  silver,  with  a  little  opium.  Fowler's  solution  and  laudanum, 
bismuth  and  carbolic  acid,  especially  the  last-named  combination,  will 
check  them  sufficiently.  Two  or  three  stools  a  day  are  not  interfered 
with,  unless  copious  and  exhausting.  Careful  alimentation  best  regu- 
lates the  bowels.  If  haemorrhage  occur,  intestinal  movements  must  be 
suspended  by  opium,  the  flow  of  blood  controlled  by  ergotin  hypoder- 
matically  and  ice  to  the  abdomen.  Tannin,  alum,  and  solution  of  chlo- 
ride of  iron  may  be  prescribed  internally.  If  perforation  occur,  opium, 
especially  morphia  hypodermatically,  is  our  one  remedy.  Stimulants 
may  be  given  cautiously,  and  absolute  rest  should  be  maintained.  Bed- 
sores are  best  managed  by  cold-water  bags  and  the  removal  of  pressure. 
Before  the  skin  breaks,  it  should  be  frequently  washed  with  alcohol 
and  Goulard's  extract  to  harden  it.  The  best  dressing  for  a  bed-sore 
is  a  mixture  of  equal  parts  of  copaiba  and  castor-oil.  A  large  yeast- 
poultice  is  an  excellent  application,  especially  when  more  or  less  weight 


704  FEVERS. 

is  still  borue  by  the  sore  surface.  The  alimentary  treatment  of  ty- 
phoid fever  is  very  important.  The  principal  lesions  being  in  the 
intestinal  canal,  the  diet  must  be  arranged  accordingly.  Dr.  George 
Johnson  has  shown  us  that  many  cases  of  typhoid  need  nothing  more 
than  rest  in  bed  and  milk  diet ;  and  Sir  William  Jenner  has  pointed  out 
how  useful  milk  is,  and  how  injudiciously  it  is  given  in  many  cases. 
We  draw  from  these  able  physicians,  that  milk  is  peculiarly  adapted 
to  serve  as  the  food  for  typhoid-fever  patients,  but  that  it  must  be 
given  in  moderate  quantity,  and  at  suitable  intervals.  Milk  should  be 
administered  about  every  three  hours,  and  from  two  to  four  ounces  at 
one  time.  Or  milk  may  be  given  in  alternation  with  a  little  weak  mut- 
ton, beef,  or  chicken  broth.  If  milk  is  not  borne  well,  it  may  be  diluted 
with  barley-water.  A  little  of  Scheffer's  pepsin  solution  and  muriatic 
acid  ought  to  be  administered  immediately  after  the  aliment,  if  it  is 
rejected  by  vomiting  or  passes  by  stool  unchanged.  Beef-essence,  as 
usually  prepared  and  given  to  typhoid-fever  patients,  is  very  difficult 
of  digestion,  acts  as  a  laxative,  and  may  be  seen  in  the  evacuations 
precisely  in  the  state  in  which  it  was  swallowed.  As  the  adynamia 
increases,  egg-nogg,  fortified  by  whisky  or  brandy,  comes  to  be  a  most 
useful  aliment,  of  which  the  patient  may  partake  freely,  but  at  regular 
intervals.  Sufficient  time  ought  to  be  allowed  for  the  aliment  given  at 
one  time  to  be  digested,  before  another  supply  is  turned  into  the  stom- 
ach. A  moderate  quantity  of  a  light  wine  should  be  allowed  during 
the  first  two  weeks,  and  whisky  and  brandy  given  in  egg-nogg  or 
milk-punch  the  third  and  fourth  weeks.  Half  an  ounce  to  an  ounce  of 
wine  and  a  half-ounce  of  whisky  or  brandy  need  rarely  be  exceeded  at 
one  time,  nor  more  frequently  than  once  in  three  hours,  unless  there  be 
a  special  requirement.  Mild  cases  need  no  stimulant.  The  dejections 
of  a  typhoid  patient  should  be  at  once  disinfected  by  a  strong  solution 
of  sulphate  of  iron  or  chloride  of  zinc.  The  patient's  bed  should  be 
free  from  all  imnecessary  appendages,  and  be  placed  in  the  middle  of 
the  apartment.  Air  should  be  freely  admitted.  But  one  person  should, 
as  a  rule,  be  permitted  in  the  apartment  at  a  time,  and  the  patient's 
attention  should  not  be  attracted  to  persons  and  things  about  him. 

Note. —  Typlio- Malarial  Fever.  By  this  term  is  meant  typhoid  fever  com- 
plicated with  a  malarial  element.  In  consequence  of  the  existence  of  a  malarial 
infection,  the  symptomatology  of  typhoid  fever  is  modified — the  chief  deviation 
from  the  usual  thermal  line  consisting  in  the  greater  excursions  of  the  daily  tem- 
perature. This  modification  of  the  fever  has  long  been  known  by  all  well-in- 
formed physicians  practicing  in  malarious  regions.  Dr.  Woodward,  of  the  army, 
the  medical  officer  in  charge  of  the  medical  history  of  the  war  of  the  rebellion, 
gave  to  this  combination  the  name  typTio-malarial  fever.  In  his  first  publica- 
tions on  this  subject,  Dr.  "Woodward  supposed  that  there  was  something  dis- 
tinctive in  this  form  of  fever,  and  that  its  morbid  anatomy  differed  in  important 
particulars  from  that  of  typhoid.     There  were  those — the  author  among  them-;— 


TYPHUS  FEVER.  Y05 

who  could  not  agree  with  Dr.  "Woodward  in  this  assumption,  and  who  maintained 
that  the  lesions  of  typho-malarial  fever  were  the  lesions  of  typhoid  only.  In  a 
paper  read  before  the  International  Medical  Congress,  at  Philadelphia,  Dr.  Wood- 
ward reti'acted  his  original  observations,  admitted  that  he  had  been  misled,  and 
that  the  morbid  anatomy  of  typho-malarial  fever  is  merely  that  of  typhoid. 
Typho-malarial  fever  has,  then,  no  reason  to  be  admitted  as  a  morbid  entity  in 
nosological  systems — does  not,  in  fact,  exist.  All  that  can  be  claimed  for  it  is, 
that  when  typhoid  fever  occurs  in  an  individual  saturated  with  malaria,  the 
fever  is  modified  somewhat  in  its  course,  has  more  of  the  remittent  type,  and 
is  apt  to  be  protracted,  owing  to  the  occurrence  of  intermittents  during  conva- 
lescence. 

The  introduction  of  the  term  typho-malarial  was  unfortunate — the  more 
especially  as,  since  the  claim  for  its  distinctive  type  having  been  permitted  to  go 
uncorrected  for  ten  years,  it  has  been  widely  received,  generally  employed,  and 
has  therefore  years  of  usage  to  enhance  its  duration.  i 


TYPHUS    FEVER. 

Definition. — A  febrile  affection,  self -limited,  and  characterized  by 
profound  adynamia,  a  peculiar  petechial  eruption,  favorable  cases 
terminating  by  crisis  at  the  end  of  the  second  week.  Typhoid  and 
typhus  are  now  almost  universally  regarded  as  distinct  affections. 
Stokes,*  however,  takes  a  different  position,  and  maintains  that  the 
points  of  resemblance  are  greater  than  the  differences. 

Causes. — As  a  rule,  typhus  prevails  in  seaport  towns,  where  it  is 
known  as  "  ship-fever  "  ;  but  it  has  under  some  circumstances  ravaged 
continents,  as  during  the  great  famine  periods  :  Ireland  has  been  deci- 
mated, and,  under  similar  circumstances,  Italy  and  Austro-Hungary 
have  been  severely  visited,  f  Typhus  now  prevails  in  crowded  ships, 
asylums,  and  jails — where  great  numbers  are  accumulated  together, 
are  depressed  by  poor  food  and  bad  air.  It  is  seen  in  this  country 
only  at  our  seaport  towns,  and  the  author's  personal  experience  is  lim- 
ited to  cases  observed  at  the  Baltimore  Infirmary,  admitted  to  the 
service  of  the  late  Professors  Power  and  Chew  from  ships  in  the  har- 
bor in  the  years  1850-'53.  How  evil  soever  may  be  the  hygienic  influ- 
ences, typhus  does  not  originate  spontaneously  ;  the  peculiar  germ  must 
be  introduced  from  without.  Of  the  nature,  form,  and  condition  of 
the  germ  we  know  nothing.  The  disease  is  contagious,  and  the  con- 
tagious principle  increases  in  virulence  the  more  crowded  and  numer- 
ous the  patients  within  a  given  area,  and  the  more  unfavorable  the 
hygienic  influences  and  the  bodily  state  of  those  attacked.  Hence  the 
terrible  force  of  the  poison  during  the  famine  periods  in  Ireland.  The 
disease  is  more  frequent  among  males  than  among  females,  and  occurs 
by  preference  during  the  most  active  period  of  life,  or  from  fifteen  to 

*  "  Lectures  on  Fever,"  London,  Longmans,  Green  &  Co.,  1874,  p.  86. 
\  "  Trait6  de  Climatologie  Medicale,"  tome  iv,  p.  362,  et  seq. 
45 


706  FEVERS. 

fifty.  Like  other  acute  infectious  diseases,  one  attack  serves  to  exempt 
from  future  attacks. 

Pathological  Anatomy. — We  do  not  find  in  typhus  the  definite 
series  of  changes  which  so  individualize  typhoid.  The  solids  and 
fluids  generally  are  deeply  injured.  Vascular  turgescence  is  noted 
in  the  ujDper  part  of  the  small  intestines  and  the  ileum.  In  the  midst 
of  stellate  or  arborescent  injection  in  the  ileum,  there  are  sometimes 
small  spots  of  ulceration,  not  all  like  the  ulcerations  of  typhoid,  and 
occurring  in  only  five  per  cent,  of  the  cases.*  Changes — thickening 
and  deposits — in  the  mesenteric  glands  are  very  uncommon.  More  or 
less  congestion  of  the  spleen,  liver,  and  kidneys,  with  granular  degen- 
eration more  or  less  advanced,  is  noted  in  a  portion  of  the  cases.  A 
similar  change — granular  degeneration — occurs  in  the  heart  as  well. 
There  is  present  some  serum  in  the  sac  of  the  pericardium.  The  blood 
is  dark,  fluid,  and  not  firmly  coagulable,  but  thrombi  are  found  adhe- 
rent to  the  walls  of  the  large  veins.  There  is  more  or  less  fluid  in  the 
subarachnoid  spaces,  and  the  membranes  and  cerebral  substance  are 
more  or  less  injected.  The  mucous  membrane  of  the  bronchi  are 
hypertemic  and  sometimes  inflamed,  and  occasionally  atelectasis  and 
pneumonia  are  encountered.  The  muscles  present  the  changes  of 
granular  degeneration. 

Symptoms. — There  may  or  may  not  be  a  prodromic  stage,  and, 
when  it  does  occur,  it  is  of  short  duration.  The  patient  is  dull,  heavy, 
dispirited,  experiences  a  strong  sense  of  fatigue,  has  headache,  is  rest- 
less and  wakeful  at  night.  In  a  few  days  the  effort  to  keep  up  is 
abandoned,  and  the  patient  betakes  himself  to  bed,  thoroughly  ex- 
hausted. In  other  cases,  of  which  the  great  Irish  epidemics  have 
furnished  numerous  examples,  the  patient  is  suddenly  seized,  and 
passes  at  once  into  a  state  of  profound  adynamia,  or  he  walks  to  the 
hospital,  is  put  to  bed,  and  in  twenty-four  hours  he  lies  helpless,  coma- 
tose, and  sinking.  There  may  be  a  slight  chill  at  the  onset,  or  nausea 
and  vomiting  may  inaugurate  the  symptoms.  A  very  severe  head- 
ache and  pains  in  the  back  and  limbs  are  now  experienced.  The  head 
feels  hot  ;  there  is  much  giddiness  when  the  attempt  is  made  to  rise  ; 
and  sneezing,  with  other  symptoms  of  catarrh,  and  noises  in  the  ears 
are  also  experienced.  The  fever  rises  rapidly  from  the  beginning, 
the  pulse  ranges  from  90  to  120  at  once,  and  the  temperature  by  the 
third  or  fourth  day  has  attained  to  103°  or  104°  Fahr.  in  the  morning 
and  105°  or  106°  in  the  evening.  Again,  it  sometimes  happens,  so  pro- 
found is  the  intoxication,  that  the  forces  are  inadequate  to  maintain 
the  pulse  at  or  above  normal  and  the  temperature  above  99°.  There 
may  be  high  temperature  temporarily  without  any  special  significance  ; 
but  persistently  high  temperature  bodes  ill.     Extreme  weakness  and  a 

*  Lyons,  op.  cit.,  p.  142,  et  seq. 


TYPHUS  FEVER.  707 

deep,  apathetic  listlessness  soon  come  on,  when  the  patient  lies  on  his 
back,  oblivious  to  all  about  him  ;  his  eyes  are  half  closed,  and  are  dull 
and  glazed  ;  his  mouth  is  half  open,  the  lips  dry  and  cracked,  the  teeth 
covered  with  sordes  ;  his  face  is  dusky,  which  is  the  general  tint  of 
the  skin,  and  the  malar  protuberance  has  a  reddish-brown  color.  To- 
ward the  end  of  the  first  week  the  characteristic  eruption  of  typhus 
makes  its  appearance  on  the  back  between  the  scapulae  in  males,  on 
the  chest  and  abdomen  in  females,  and  spreads  thence  over  the  rest  of 
the  body.  They  ai-e  a  half  line  to  a  line  in  diameter,  reddish-brown 
in  color,  a  little  elevated  above  the  general  surface,  disappearing  on 
pressure,  to  reappear  when  the  pressure  is  removed.  They  may  be 
very  numerous,  so  that  a  dozen  will  be  contained  in  a  square  inch,  or 
they  may  be  sparse  and  larger  in  size.  Successive  crops  appear,  and 
the  duration  of  the  eruption  stage  is  from  five  to  seven  days,  so  that  it 
may  be  expected  to  disappear  from  the  twelfth  to  the  fourteenth  day. 
Prognostications  may  be  drawn  from  the  appearance  of  the  eruption. 
If  it  is  rose-colored,  the  general  tint  of  the  skin  being  good,  the  condi- 
tion is  favorable  ;  if  a  dusky-brown,  rather  livid  color,  the  skin  also 
dusky,  the  condition  is  unfavorable.  Trousseau  *  formulates  the  sig- 
nificance of  the  eruption  as  follows  :  "  The  gravity  and  duration  of 
the  malady  are  in  relation  to  the  abundance  and  depth  of  color  of  the 
eruption."  Besides  the  measles-like  eruption,  which  is  characteristic, 
there  are  in  some  epidemics  spots  and  patches  of  purpura,  of  vary- 
ing size,  and  the  larger  extravasations  known  as  vibices.  Both  of 
these  indicate  a  low  form  of  the  disease,  and  are,  therefore,  symptoms 
of  evil  augury,  Sudamina  also  occur,  but  these  have  no  special  sig- 
nificance, unless  differing  from  ordinary  sudamina  in  the  character  of 
their  contents,  which,  if  bloody,  or  having  a  putrescent  odor,  show  a 
bad  state  of  the  tissues.  At  the  close  of  the  first  or  beginning  of  the 
second  week,  instead  of  there  being  a  merely  clouded  state  of  the  men- 
tal faculties,  active  delirium  may  ensue.  It  may  be  very  violent,  the 
patient  difficult  of  control,  striking  and  fighting  all  who  approach,  try- 
ing to  get  out  of  bed,  etc.  This  condition,  which  has  been  happily 
designated  delirhon  ferox,  may  continue  for  days  and  nights,  the 
patient  sleeping  none,  there  being  at  the  same  time  intense  fever, 
rapid  action  of  the  heart,  injected  conjunctivae,  great  intolerance  of 
light,  and  contraction  of  the  pupils.  But  this  active  and  violent 
delirium  is  much  less  common  than  low-muttering  delirium  in  which 
the  illusions  and  hallucinations  form  the  topics  of  the  unintelligible 
rambling.  The  patient  usually  lies  in  an  entirely  passive  state,  taking 
food  mechanically,  sleeping  but  little,  although  in  a  constant  sopo- 
rose state,  the  pulse  ranging  from  120  to  140,  double-beating,  easily 
compressible,  the  surface  of  the  body  presenting  a  dusky,  cyanosed 

*  "  Clinique  Medicale,"  tome  i,  p.  299. 


708  FEVERS. 

appearance,  and  the  actual  condition  being  that  of  profound  and  in- 
creasing prostration.  There  is  usually  some  dry  cough.  The  bowels 
are  at  first  rather  confined,  and  during  the  height  of  the  disease  the 
dejections  are  scanty,  rather  infrequent,  but  consist  of  somewhat  loose, 
offensive,  dark  stools.  There  is  no  distention  of  the  abdomen.  The 
spleen  is  enlarged,  and  can  be  made  out  projecting  downward.  The 
urine  is  scanty,  high-colored,  specific  gravity  high,  and  usually  con- 
tains albumen.  During  the  stupor,  urine  and  faeces  are  passed  in- 
voluntarily. A  very  peculiar  and  distinctive  odor  is  maintained  by 
many  to  exist.  Trousseau  regards  it  as  sui  generis  /  but  we  believe  it 
to  be  similar  to  that  which  is  to  be  detected  about  all  fever-patients 
so  oblivious  to  their  natural  wants.  During  the  second  week  the  pros- 
tration is  so  profound  that  patients  die,  without  any  special  compli- 
cation, from  failure  of  the  heai't.  The  temperature  of  the  skin  falls; 
the  purpuric  spots  enlarge  ;  parts  exposed  to  pressure — the  sacrum 
especially — soften  and  ulcerate  ;  the  pulse  becomes  small  and  irregu- 
lar ;  the  impulse  of  the  heart  is  scarcely  perceptible,  and  the  first 
sound  is  no  longer  audible.  In  this  condition  the  patient  may  remain 
for  a  day  or  two,  even  longer,  suspended  between  life  and  death — the 
stupor  may  deepen  into  fatal  coma,  or  death  may  be  induced  by  sud- 
den engorgement  of  the  lungs,  or  the  heart  fails,  the  jjulse  becomes 
imperceptible  at  the  wrist,  and  the  surface  cold,  and  covered  with  a 
cold  sweat.  Instead  of  a  fatal  termination,  a  large  proportion  recover. 
About  the  fourteenth  day,  if  a  change  for  the  better  is  to  occur,  phe- 
nomena of  a  rather  critical  character  supervene.  The  patient  falls 
into  a  quiet  sleep  lasting  several  hours,  and  he  awakes  refreshed,  and 
with  consciousness  restored,  but  oblivious  of  all  that  has  transpired, 
and  feeling  an  extreme  degree  of  feebleness.  The  pulse  lessens  in  fre- 
quency, but  gains  in  volume  ;  the  tongue  begins  to  clean  and  is  moist ; 
the  skin  is  covered  with  a  warm  perspiration,  and  a  little  appetite  is 
felt.  The  critical  phenomena  which  may  accompany  this  change  for 
the  better  consist  of  a  free  sweat,  a  diarrhoea,  or  an  abundant  urinary 
discharge,  with  large  deposits  (Murchison  *). 

Course,  Duration,  and  Termination. — There  are  great  variations  in 
the  course  of  cases  of  typhus  during  the  epidemics.  In  the  mildest 
cases  the  pulse  may  not  exceed  100,  the  tongue  may  never  become  dry 
and  brown,  there  may  be  only  temporary  confusion  of  mind,  and  some- 
what troubled  sleep.  There  are  extreme  cases,  in  which  the  patient  is 
stricken  down  with  the  intensity  of  the  poison,  and  at  once  passes  into 
a  state  of  profound  prostration,  with  disorganization  of  the  blood  ; 
and,  without  any  complication  to  account  for  it,  life  is  extinguished  in 
a  few  days  after  the  onset  of  the  disease.  Usually,  however,  the  fatal 
result  may  be  referred  to  the  rise  of  some  complication.     Some  of  the 

*  Murchison  "  On  Fevers,"  op.  cit. 


TYPHUS  FEVER.  7O9 

most  important  are  the  pulmonary  :  bronchitis,  hypostasis,  pneumonia, 
gangrene  of  the  lung,  and  pleurisy.  During  the  course  of  typhus, 
frequent  examinations  should  be  made  of  the  thoracic  organs,  since 
the  insensibility  is  so  profound  that  the  patient  may  not  present  any 
indications  of  the  complications.  Especially  should  an  increased  ra- 
pidity of  breathing  become  manifest,  or  the  alae  of  the  nose  labor,  or 
the  lividity  of  the  face  deepen,  attention  should  at  once  be  directed 
to  the  state  of  the  thoracic  organs.  The  most  usual  of  the  thoracic 
complications  is  bronchitis,  and  it  is  not  always  shown  by  cough,  but 
only  by  moist  rales.  The  danger  consists  in  an  extension  to  the 
smaller  tubes,  and  the  association  of  hypostatic  congestion  with  capil- 
lary bronchitis.  When  the  adynamia  is  very  deep,  the  tubes  may 
become  paretic,  and  can  not  expel  the  accumulating  mucus,  death  oc- 
curring in  asphyxia.  The  association  of  hypostatic  congestion  with 
bronchitis  is  the  most  usual  cause  of  death  in  typhus,  taking  the  gen- 
eral order  of  cases.  Pneumonia  is  uncommon,  but  gangrene  is  com- 
paratively frequent  in  famine-typhus.  Thrombosis  of  the  femoral 
artery  sometimes  occurs,  but  the  chief  complications  on  the  part  of 
the  blood  are  those  due  to  its  disorganization  :  purpuric  spots,  haemor- 
rhages by  the  nose,  bronchial  tubes,  stomach,  intestines,  and  kidneys, 
and  a  more  or  less  extensive  general  cyanosis.  Imbecility  and  mania 
are  sometimes  sequences  of  typhus,  but  there  are  complications  of  a 
paralytic  kind  occurring  during  the  course  of  the  fever,  or  during  con- 
valescence, such  as  hemiplegia,  paraplegia,  or  affections  of  the  special 
senses,  amaurosis,  and  especially  deafness.  These  are  usually  tempo- 
rary, and  due  to  the  extreme  degree  of  anaemia  produced  by  the  fever, 
but  some  of  them  are  more  permanent,  as  the  deafness  due  to  suppu- 
ration of  the  middle  ear.  Complications  on  the  part  of  the  skin  are 
often  very  severe,  notably  the  extensive  bed-sores,  gangrene  of  the 
skin,  and  furuncles.  A  whole  extremity  may  become  gangrenous. 
Erysipelas  of  the  scalp  and  face,  suppuration  of  the  parotid  gland,  and 
buboes,  are  also  encountered.  All  of  these  complications  increase  the 
gravity  of  the  case,  and  in  proportion  to  their  importance.  The  dura- 
tion is  also  more  or  less  influenced  by  the  complications.  The  ordinary 
duration  of  a  mild,  uncomplicated  case  is  about  three  weeks.  The 
Germans  recognize  an  abortive  form  of  typhus,  terminating  by  crisis 
about  the  seventh  day,  but  such  cases,  it  seems  to  the  author,  belong 
to  a  different  order.  A  case  of  typhus  may  be  protracted  by  compli- 
cations four,  five,  or  six  weeks.  Even  in  the  severer  epidemics  the 
majority  recover.  Much  depends  on  the  type  of  the  cases.  Those 
characterized  by  intense  fever  and  active  delirium  are  called  inflam- 
matory;  those  in  which  the  merely  nervous  symptoms,  as  delirium, 
stupor,  subsultus  tendinum,  predominate,  are  designated  ataxic  ;  and 
those  in  which  a  profound  prostration  comes  on  are  known  as  ady- 
namic (Murchison).     In  the  severe  epidemics  which  have  visited  Ire- 


710  FEVERS. 

land  and  India  one  fifth  have  proved  fatal,  and  this  was  the  mortality 
at  the  London  Fever  Hospital  for  fourteen  years.  In  some  epidemics, 
the  mortality  has  risen  to  forty  per  cent.,  and  even  higher,  and  in 
others  has  fallen  to  eight  per  cent.  The  type  of  the  epidemic,  as  well 
as  of  individual  cases,  is,  therefore,  a  large  factor  in  determining  the 
mortality.  The  mean  mortality  is  from  fifteen  to  twenty  per  cent. 
The  disease  is  more  fatal  in  males  than  in  females,  and  is  less  fatal  in 
childhood,  the  mortality  increasing  with  age. 

Diagnosis. — Stokes  is  the  only  author  of  any  prominence  advocating 
the  identity  of  typhoid  and  typhus.  The  prodromic  stage  is  more 
usual  and  protracted  in  typhoid  ;  the  onset  of  stupor  and  delirium  is 
earlier  and  more  pronounced  in  typhus  ;  in  typhoid  there  are  meteor- 
ism,  gurgling  in  the  right  iliac  fossa,  and  diarrhoea — in  typhus  these 
are  wanting  ;  in  typhoid  there  is  a  roseola  eruption  of  a  small  number 
of  spots ;  in  typhus  there  is  a  petechial  eruption,  which  is  abundant 
over  the  body  ;  the  duration  of  typhus  without  comiDlications  is  about 
two  weeks,  often  terminating  with  crisis — of  typhoid,  four  weeks,  by 
slow  decline  of  fever  ;  on  post-iinortem,  examination,  thickening  and 
ulceration  of  Peyer's  patches  and  of  the  solitary  glands  and  enlarge- 
ment and  softening  of  the  mesenteric  glands  are  seen  in  typhoid, 
while  no  similar  or  corresponding  changes  take  place  in  typhus. 

Treatment. — The  same  means  of  treatment  pursued  in  typhoid  are 
equally  applicable  here,  except  that  the  adynamic  condition  appears 
sooner,  and  is  more  profound,  requiring  a  somewhat  earlier  resort  to 
stimulants.  The  alimentation  should  be  carefully  prescribed  from 
the  beginning,  and  should  consist  of  milk,  eggs,  animal  broths,  and  a 
moderate  quantity  of  wine,  which  should  be  changed  to  whisky  or 
brandy  as  the  prostration  increases.  Still  more  than  in  typhoid  is  it 
necessary  in  typhus  to  keep  the  temperature  within  safe  limits  by  the 
use  of  antipyretics.  Cold  baths,  or  the  wet  pack,  quinia,  and  digitalis, 
are  used  as  in  the  treatment  of  typhoid,  under  the  same  rules  and  reg- 
ulations. As  certain  critical  phenomena  may  ensue  at  or  about  the 
end  of  the  second  week,  it  is  important  to  be  prepared  for  them,  lest 
the  revolution  which  then  takes  places  may  tax  too  heavily  the  vital 
resources.  As  typhus  is  distinctly  contagious,  isolation  of  the  patient 
is  demanded  by  every  consideration,  and  all  of  the  patient's  excretions 
should  be  disinfected  and  removed  without  delay. 


RELAPSING  FEVER. 

Definition. — This  is  an  acute,  infectious,  febrile  disease,  self -limited, 
and  characterized  by  the  occurrence  of  a  febrile  paroxysm,  lasting 
about  one  week,  succeeded  by  an  entire  intermission  of  four  or  five 
days'  duration,  which  is  in  turn  followed  by  a  relapse  like  the  first 
seizure,  although  shorter. 


RELAPSING  FEVER.  711 

Causes. — Relapsing  fever  is  a  distinctly  contagious  affection.  Some 
excellent  illustrations  of  the  modes  in  which  it  may  be  communicated 
have  been  narrated  by  Parry,*  and  every  epidemic  furnishes  examples. 
The  poison  acquires  the  greater  activity  the  more  filthy,  crowded,  and 
unhealthy  the  population  amid  which  it  prevails.  The  larger  the 
number  of  sick,  ill  with  the  disease,  crowded  into  a  given  locality,  and 
the  more  unhygienic  the  local  conditions  about  the  sick,  the  more  viru- 
lent becomes  the  poison.  Articles  of  clothing  which  have  been  about 
the  sick  will  retain  the  contagious  principle  for  a  long  time,  and  those 
who  have  been  in  the  presence  of  the  sick  can  convey  the  poison  to 
the  healthy  at  a  distance.  It  seems  in  a  high  degree  probable  that 
drinking-water  may  be  contaminated  and  spread  the  poison.  So  rap- 
idly are  members  of  a  family  attacked,  after  one  case  has  been  intro- 
duced, that  some  general  cause  might  be  supposed  to  act  on  all  simul- 
taneously. The  disease  attacks  by  preference  the  young,  the  liability 
lessening  after  thirty,  and  apparently  ceasing  after  fifty.  In  this  dis- 
ease we  seem  nearer  than  in  almost  any  other  to  a  correct  knowledge 
of  the  nature  of  the  morbific  principle,  since  the  discovery  by  Ober- 
meier  in  1873  of  a  minute  organism  in  the  blood  of  relapsing-fever 
patients.  Unlike  most  of  the  other  fevers,  the  occurrence  of  one  at- 
tack of  relapsing  fever  does  not  purchase  an  immunity  against  subse- 
quent attacks  ;  indeed,  the  liability  to  it  seems  rather  increased  by  pre- 
vious attacks.  An  intimate  relation  apparently  exists  between  relapsing 
fever  and  typhus,  for  Lebert  has  ascertained  that,  of  fifty-three  cases 
of  relapsing  fever,  all  were  attacked  with  typhus  within  a  few  weeks  to 
several  months.  Although  the  natural  home  of  relapsing  fever  is  Ire- 
land, it  has  spread  over  England,  on  to  the  Continent,  and  has  reached 
this  couiltry,  distinct  epidemics  having  occurred  since  1850  in  New 
York,  Philadelphia,  and  other  cities.     It  occurs  at  all  seasons. 

Pathological  Anatomy. — The  alterations  produced  by  relapsing  fever 
are  by  no  means  characteristic.  During  life  minute  organisms  are 
found  in  the  blood,  but,  according  to  Lebert,f  "  they  were  searched  for 
in  vain  in  the  spleen,  lungs,  and  other  organs."  During  the  primary 
attack  and  relapse  these  organisms  are  present,  but  they  disappear,  or 
usually  do,  during  the  period  of  intermission.  These  bodies  consist  of 
minute  spiral  filaments,  constantly  in  motion.  They  never  exceed  O'OOl 
mm.  in  diameter,  and  0*15  to  0-2  mm.  in  length  (Lebert).  The  very 
lively,  twisting,  and  elongating  motions  of  these  spiral  bodies  cease  as 
the  blood  coagulates,  and  those  observed  in  the  serum  of  the  blood  are 
often  embraced  in  a  granular  substance,  probably  albuminous.|     The 

*  Dr.  J.  S.  Parry,  "The  American  Journal  of  the  Medical  Sciences,"  October,  18*70. 

f  Ziemssen's  "  Cyclopaedia,"  vol.  i,  op.  cit. 

X  Dr.  Paul  Guttmann  ("  Verhandlungen  der  physiologische  Gesellschaft  zu  Berlin," 
No.  7,  1880)  has  examined  the  blood  of  more  than  two  hundred  cases  of  relapsing  fever, 
and  finds  the  characteristic  spirilli  of  Obermeier  only  during  the  pyretic  period.     These 


712  FEVERS. 

relative  proportion  of  white  blood-corpuscles  is  increased.  The  spleen 
is  usually  considerably  enlarged,  and  may  be  either  firm  or  soft.  "  Mil- 
iary aggregations  of  a  dull-yellow  color,  and  containing  granular  de- 
tritus, with  occasionally  cell-elements  and  free  nuclei,"  are  found  in  the 
spleen  in  some  cases,  and  in  other  cases  "  wedge-shaped  infarctions." 
These  may  be  supposed  to  have  their  origin  in  embolisms  formed  by 
masses  of  the  spiral  organism.  The  liver  is  also  somewhat  enlarged, 
and  the  acini  are  in  many  instances  pale  and  clouded  ;  and  there  are, 
rarely,  it  must  be  admitted,  minute  deposits  like  those  mentioned  as 
present  in  the  spleen.  The  gall-bladder  is  full.  The  kidneys,  like  the 
liver  and  sj^leen,  are  somewhat  swollen  ;  the  cortex  is  pale,  and  cloudy 
swelling  and  granular  infiltration  are  to  be  seen  in  the  tubules.  In 
the  intestinal  canal  some  thickening  of  the  solitary  glands  and  patches 
of  Peyer  occurs,  also  in  the  mesenteric  glands  ;  but  these  changes  are 
trivial  as  compared  with  those  of  typhoid  fever.  Sometimes  in  vari- 
ous parts  of  the  mucous  membranes  minute  extravasations  of  blood 
are  found.  The  only  change  in  the  heart  is  a  granular  condition  of 
its  muscular  tissue,  such  as  occurs  in  febrile  affections,  and  a  similar 
change  is  to  be  seen  in  the  muscles,  generally  due  to  the  same 
cause. 

Symptoms. — From  the  period  of  exposure,  or  of  reception  of  the 
morbific  material,  until  the  first  phenomena  of  the  disease  are  manifest 
— the  incubation — about  five  to  seven  days  elapse.  This  is  not  invari- 
able, and  must  therefore  be  regarded  as  a  close  approximation  only. 
There  is  no  real  prodromic  period.  Just  as  the  disease  is  about  to 
appear  the  patient  experiences  a  general  malaise — some  pains  in  the 
head  and  limbs,  wakefulness,  loss  of  appetite,  etc.  The  malady  begins 
rather  abruptly  with  fever,  in  only  one  half  of  the  cases  is  there  chil- 
liness, and  in  a  much  smaller  number  a  distinct  rigor.  In  some  epi- 
' demies  there  are  irregular  chills,  and  occasional  sweats  for  the  first 
two  or  three  days,  simulating  an  intermittent  fever.  In  many  cases 
the  fever  is  high  and  the  symptoms  severe  from  the  beginning ;  in 
other  cases  the  patient  keeps  about  for  the  first  few  days.  With  the 
initial  fever  there  are  usually  nausea  and  vomiting,  and,  if  not  in  the 
beginning,  in  a  very  short  time  there  is  a  marked  degree  of  debility. 
The  fever  is  of  the  remittent  type,  with  a  morning  remission  and  an 
evening  exacerbation — the  morning  temperature  being  at  102°  to  103° 
Fahr.,  and  the  evening  temperature  at  104°  to  105°.  The  pulse  cor- 
responds, ranging  from  110  in  the  morning  to  130  in  the  evening,  and 
is  rather  weak,  usually  dicrotic,  or  wanting  in  tension.  The  tongue 
is  coated  and  soon  becomes  very  dry  and  sore  ;  the  bowels  are  consti- 
pated. The  chief  source  of  suffering  at  the  outset  is  the  pain  in  the 
back  and  limbs,  but  all  the  muscles  of  the  body  soon  become  the  seat 

new  observations  confirm  what  is  stated  in  the  text.  Dr.  Guttmann  further  shows  that 
the  spirilli  are  genuine  parasites.     (See  also  Virchow's  "Archiv,"  Band  Ixxx,  s.  i,  1880.) 


RELAPSING  FEVER.  YI3 

of  very  violent  grinding,  piercing,  lancinating  pains,  and  these  pains 
are  increased  by  movement  or  pressure.  The  most  aggravated  of 
these  pains  are  those  felt  in  the  calf  of  the  leg.  The  headache,  which 
was  so  pronounced  in  the  beginning,  lessens  somewhat  in  severity  as 
the  muscular  pains  develop.  About  the  second  day  a  painful  sense  of 
weight  and  pressure  is  experienced  in  the  right  and  left  hypochon- 
drium,  especially  in  the  left,  and  is  caused  by  enlargement,  with  con- 
gestion, of  the  liver  and  spleen.  The  spleen  especially  enlarges  very 
considerably,  projecting  below  the  ribs.  The  area  of  hepatic  dullness 
is  also  much  increased,  and  the  margin  of  the  liver  can  be  felt  several 
fingers'  breadths  beyond  the  ribs.  This  increase  in  the  dimensions  of 
these  organs  begins  on  the  second  day,  and  increases  day  by  day,  to 
diminish  during  the  interval  or  intermission.  Besides  the  increase  in 
volume,  these  organs  become  very  sensitive  to  pressure,  and  continue 
tender  as  long  as  they  are  enlarged.  There  is  no  tympanitic  disten- 
tion of  the  abdomen,  no  diarrhoea,  no  rose-spots,  but  more  or  less  vom- 
iting persists  during  several  days,  the  vomited  matters  consisting  of  a 
greenish,  acid  fluid.  There  is  no  delirium,  the  nights  are  much  dis- 
turbed by  pain,  but  the  mind  is  unclouded.  The  urine  frequently 
contains  albumen,  but  its  composition  in  other  respects  is  that  of  the 
urine  of  febrile  diseases  in  general.  More  or  less  sweating  occurs,  but 
no  amelioration  of  the  fever  is  produced,  for  the  skin  continues  hot, 
while  there  is  a  general  moisture  of  the  surface.  The  fever,  the  pains, 
the  nausea  and  vomiting,  the  tumefaction  of  the  liver  and  spleen,  con- 
tinue up  to  the  end  of  the  paroxysm.  It  is  not  surprising  that,  under 
these  circumstances,  there  should  be  weakness  and  emaciation.  In  a 
small  proportion  of  cases  jaundice  appears  at  some  period  during  the 
first  paroxysm.  Toward  the  end  of  the  first  week,  on  the  fifth,  sixth, 
or  seventh  day,  all  of  the  symptoms  attain  their  maximum  and  the 
case  looks  truly  formidable,  when  a  sudden  defervescence  takes  place, 
and  with  it  a  remarkable  diminution  in  all  of  the  symptoms.  Profuse 
sweating  sets  in,  and  the  temperature  falls  to  normal  and  below,  a 
variation  of  five  or  six  degrees  taking  place  from  night  to  morning. 
The  pulse  also  descends  from  the  high  point  at  which  it  had  been  at 
the  maximum,  to  the  normal,  or  even  below.  Corresponding  changes 
ensue  in  the  other  symptoms.  A  feeling  of  comparative  comfort  is 
substituted  for  the  severe  pains  ;  appetite  replaces  nausea  or  disgust 
for  food  ;  the  bowels  act  normally  ;  the  swelling  and  tenderness  of  the 
liver  and  spleen  disappear,  and  the  jaundice,  if  present,  begins  to  fade  ; 
the  tongue  clears  off  ;  sleep  is  restored,  and  the  strength  gains  rapidly, 
so  that  in  a  day  the  patient  is  disposed  to  get  up  and  regards  himseK 
as  well,  although  somewhat  weak.  The  improvement  continues,  and 
hence  it  is  a  matter  of  extreme  surprise  to  the  patient,  if  unfamiliar 
with  the  nature  of  the  malady,  to  be  attacked  with  a  relapse.  The 
period  of  intermission  is  not  a  fixed  period,  and  varies  from  four  days 


fll4:  FEVERS. 

to  one  week,  very  rarely  to  two  weeks.  Comj)lete  recovery  lias  not 
therefore  taken  place  when  the  relapse  occurs.  Quite  suddenly,  in  the 
afternoon,  in  the  evening,  or  more  frequently  at  night,  the  relapse 
comes  on  with  a  chill  which  is  rather  exceptional,  or  a  sense  of  chilliness, 
or  with  fever  only.  The  relapse,  as  a  rule,  repeats  the  symptoms  of 
the  initial  seizure,  except  that  its  course  is  less  severe  and  of  somewhat 
shorter  duration  ;  but  the  pains,  nausea,  and  vomiting,  enlargement  of 
the  liver  and  spleen,  are  very  much  the  same.  The  fever  has  more  of 
a  remittent  type,  and  the  sweats  have  a  somewhat  critical  aspect,  for 
more  relief  is  afforded  by  them  than  during  the  primary  paroxysm.  An 
attempt  at  critical  phenomena  may  be  made  a  day  or  two  before  the 
real  crisis  ;  there  may  be  a  considerable  sweat  and  a  marked  fall  of 
temperature;  but  the  effect  is  not  maintained  and  the  temj^erature  rises 
again.  The  final  defervescence  occurs  from  the  third  to  the  fifth  day, 
and  usually  at  night,  when  a  profuse  sweat  occurs,  and  the  temperature 
and  the  pulse-rate  fall  below  normal.  The  crisis  may  be  postponed  to 
the  seventh  day,  but  this  is  not  usual.  A  second,  a  third,  even  a  fourth 
relapse  has  been  noted  in  some  epidemics.  The  symptoms  are  the 
same,  but  the  more  numerous  the  relapses,  the  more  reduced  must  the 
patient  become  by  a  repetition  of  the  suffering. 

Course,  Duration,  and  Termination. — The  whole  course  of  an  ordi- 
nary case  of  relapsing  fever  is  concluded  within  three  weeks,  unless 
thei'e  be  several  relapses.  At  the  conclusion  of  the  relapse,  the  patient 
lies  in  a  condition  of  great  comparative  comfort,  but  much  emaciated 
and  quite  exhausted.  The  ansemia  is  very  marked,  there  is  more  or 
less  oedema  of  the  ankles,  the  eyelids  are  puffy,  and  the  sclerotic 
pearly  white.  The  convalescence  is  very  slow.  Much,  of  course,  de- 
pends on  the  violence  of  the  seizures,  and  the  number  of  relapses. 
Age  appears  to  have  an  influence,  for,  in  children  under  twelve.  Parry 
observed  that  the  course  of  the  disease  was  shorter  and  milder.  There 
ai*e  also  differences  in  different  epidemics  in  respect  to  the  duration 
and  severity  of  the  disease.  The  usual  termination  is  in  health,  the 
mortality  being  about  two  to  three  per  cent.  Complications  may  have 
a  very  great  influence  over  the  result.  Bronchitis,  catarrhal  pneumo- 
nia, and  pleuritis,  occur  in  some  epidemics,  and  laryngitis  has  requii'ed 
tracheotomy.  At  the  period  of  crisis,  haemorrhages  may  occur,  notably 
epistaxis  and  local  paralyses — of  the  deltoid,  for  examj^le — have  been 
observed.  Diarrhoea  has  occurred  at  the  crisis  instead  of  a  sweat — in 
some  epidemics  increasing  the  mortality.  A  pregnant  woman  ill  with 
relapsing  fever  is  almost  certain  to  abort,  and  hence  this  must  be 
regarded  as  a  serious  complication.  At  the  period  of  crisis,  fatal  syn- 
cope has  occurred  without  any  apparent  reason.  The  extraordinary 
revolution  which  then  takes  place  may  impose  too  great  a  strain  on  a 
weak  heart.  The  persistence  of  changes  in  the  liver  and  spleen,  after 
recovery   from   the   fever,   must    place   these   affections    among   the 


YELLOW  FEVER.  Y15 

sequelae.     In  the  same  category  is  a  form  of  ophthalmia  which  has 
occurred  after  certain  epidemics. 

Treatment. — The  remedial  management  of  relapsing  fever  must 
necessarily  be  expectant.  We  possess  no  agent  to  prevent  the  develop- 
ment of  the  spirilla  in  the  blood,  and  we  do  not  know  how  this  para- 
site enters  the  blood,  or  whence  it  comes.  The  treatment  of  the  fever 
would  seem  to  require  the  use  of  antipyretics,  but  their  utility  is  very 
limited  owing  to  the  short  duration  of  the  paroxysm.*  The  best  means 
of  relieving  the  severe  pains  are  the  hypodermatic  injection  of  morphia 
and  the  wet  pack.  Opium  by  the  stomach  has  but  little  effect,  appar- 
ently, in  this  disease.  For  the  nausea,  the  best  remedy,  probably,  is 
carbolic  acid  (half  a  grain)  administered  in  cherry-laurel  water.  For 
the  nocturnal  pain  and  wakefulness,  a  combination  of  chloral  and  mor- 
phia promises  best.  The  enormous  production  of  spirilla  during  the 
paroxysms  of  fever  and  their  disappearance  in  the  intermission  are 
strong  arguments  in  favor  of  the  administration  of  parasiticides.  The 
use  of  quinia  has  been  quite  fruitless.  But  a  more  systematic  admin- 
istration of  the  sulphites  and  the  disengagement  of  sulphurous-acid 
gas  in  the  air  of  the  sick-apartment  should  be  attempted.  At  the 
period  of  crisis,  syncope  may  be  prevented  by  the  timely  use  of  alco- 
holic stimulants.  It  is  especially  during  the  period  of  intermission 
that  an  attempt  ought  to  be  made  to  prevent  the  new  development  of 
the  spirilla  which  it  is  supposed  then  takes  place.  Suitable  food,  iron, 
and  other  tonics  should  be  given  to  improve  the  quality  of  the  blood  ; 
the  increased  volume  of  the  spleen  reduced,  and  the  over-production 
of  white  corpuscles  prevented  by  the  administration  of  quinia  and  er- 
gotin,  and  an  attempt  made  to  prevent  the  new  growth  of  the  parasite 
by  the  free  use  of  the  sulphites  and  other  parasiticides. 

YELLOW    FEVER. 

Definition. —  Yelloxo  fever  is  an  acute,  infectious  disease,  occurring 
only  south  of  48°  north  latitude,  in  regions  having  a  mean  annual  tem- 
perature of  not  less  than  70°  Fahr.,  endemic  on  the  seacoast,  and  spo- 
radic elsewhere  under  an  elevation  less  than  twenty-five  hundred  feet 
above  the  sea-level,  the  germ  being  introduced  and  certain  localizing 
conditions  favoring  its  development. 

Causes. — Pursuing  the  plan  heretofore  followed,  the  author  will  not 
occupy  space  with  controversial  questions.  The  cases  (private)  seen  by 
the  author  occurred  in  the  Mississippi  Valley,  and  were  encountered  at 
Cincinnati,  having  come  there  from  infected  localities  in  the  South, 

*  As  this  work  is  going  through  the  press,  Dr.  Riess,  of  Berlin,  reports  that  he  has 
found  the  salicylate  of  soda  remarkably  effective  in  reducing  the  temperature,  and,  if 
given  in  large  doses  for  some  days,  will  lessen  the  severity,  and  even  prevent  the  relapse 
("Berliner  klinische  Wochenschrift,"  No.  lii,  1879). 


716  FEVERS. 

especially  Memphis.  It  seems  necessary  to  the  production  of  yellow 
fever  that  a  peculiar  germ  or  morbific  principle  be  introduced  from 
without.  For  the  further  development  of  this  germ  it  is  necessary 
that  there  be  a  concurrence  of  certain  telluric  and  personal  condi- 
tions. It  is  needless  to  discuss  here  whether  the  poison  ever  arises 
spontaneously  in  its  natural  habitat  under  the  necessary  conditions. 
Of  the  nature,  form,  and  composition  of  the  morbific  principle,  nothing 
is  as  yet  known,  and  the  last  investigations  in  regard  to  it  have  proved 
as  barren  of  results  as  the  preceding  one.  We  know  that  a  mean  an- 
nual temperature  of  about  72°  is  necessary  to  its  activity,  and  that  cold 
— a  frost — suffices  to  destroy  it.  A  fall  of  temperature  short  of  that 
necessary  to  suspend  the  activity  of  the  poison  increases  the  mortality 
from  it.  Yellow  fever  occurs  in  maritime  cities  first,  and  extends 
thence  to  towns  and  cities  having  direct  communication  with  them  by 
river  or  by  railroad.  Cities  and  towns,  removed,  by  reason  of  their 
situation,  from  intercourse  with  infected  maritime  cities,  escape  epi- 
demic visitation.  The  disease  does  not  spread  from  city  to  city  so 
rapidly  as  men  move  from  one  to  the  other.  A  germ  or  germs  are 
introduced.  Accumulated  filth,  decomposing  animal  and  vegetable 
matters,  bad  or  no  drainage,  crowding,  and  other  hygienic  evils,  are 
indispensable  to  impart  the  necessary  vitality.  Lodging  thus  in  a 
suitable  soil,  and  with  the  appropriate  atmospherical  conditions  present, 
the  disease-germs  grow  and  infect  those  in  the  proper  personal  state 
to  receive  the  poison.  After  a  time,  from  this  newly  infected  locality, 
germs  are  transmitted  to  other  localities.  The  conditions  existing  on 
shipboard  seem  peculiarly  favorable  to  the  growth  of  the  poison.  Next 
to  the  ship,  as  a  nidus  for  yellow  fever,  is  the  large  maritime  city, 
situated  at  the  outlet  of  a  great  river,  subject  to  annual  overflow  and 
filled  with  all  the  materials  of  insalubrity.*  To  these  must  be  added 
the  atmospherical  peculiarities  of  July,  August,  and  September.  When 
the  disease-germs  are  introduced,  and  the  localizing  conditions  are 
favorable,  not  all  persons  are  attacked.  Some  present  a  peculiar  sus- 
ceptibility, others  insusceptibility  to  the  action  of  the  poison.  Race 
exercises  a  remarkable  influence,  the  pure  negro  possessing  a  singu- 
lar immunity  against  the  infection,  provided  he  has  not  lived  outside 
of  the  yellow-fever  zone  and  returned  to  it  just  before  an  outbreak. 
Any  considerable  admixture  of  white  blood  destroys  the  protection. 
Whites  are  more  susceptible  the  farther  removed  from  the  yellow- 
fever  zone  they  have  lived  previously.  Long  residence  in  the  infected 
locality,  especially  passing  through  a  period  of  epidemic  prevalence  of 
the  disease,  and  still  more  effectually  passing  through  an  attack,  pro- 
cure more  or  less  complete  immunity  ;  but  this  immunity  may  be  lost 

*  See  Dr.  WoodhuU's  (Surgeon  U.  S.  A.)  account  of  "  The  Causes  of  the  Epidemic  of 
Yellow  Fever  at  Savannah,  Georgia,  in  IS'ze,"  ."The  American  Journal  of  the  Medical 
Sciences,"  July,  1877. 


YELLOW  FEVER.  Yl7 

and  susceptibility  restored  by  any  protracted  stay  outside  of  the  yellow- 
fever  zone.  This  process  of  hardening  against  the  reception  of  yellow 
fever  is  called  acclimation.  It  is  not  by  personal  contact  that  the  dis- 
ease is  communicated — in  other  words,  it  is  not  a  contagious  *  but  an 
infectious  disease,  and  it  is  not  against  individuals  that  quarantine 
restrictions  should  be  enforced,  but  against  articles  of  clothing,  bed- 
ding, or  the  like,  or  against  all  foraites.  The  condition  of  the  indi- 
vidual opposes  or  favors  the  reception  of  the  poison.  Besides  all  those 
conditions  which  favor  or  retard  the  spread  of  the  poison  above  men- 
tioned, must  be  stated  the  habits  of  the  individual.  All  excesses 
in  drinking  or  venery  either  help  the  reception  of  the  poison  or  in- 
crease the  virulence  of  its  action  in  the  body.  All  depressing  moral 
emotions,  especially  fear,  act  unfavorably. 

Pathological  Anatomy. — Not  much  wasting  of  the  body  is  observed, 
and  the  post-mortem  rigidity  is  usually  well  marked.  The  color  of 
the  skin  is  light  or  dark  yellow,  a  change  which  appears  to  be  never 
wanting  in  genuine  cases.  The  skin  is  also  stained  by  haemorrhagic 
extravasation,  ecchymoses,  vesicular  eruptions,  and  gangrenous  vesica- 
tions at  points  where  irritating  applications  had  been  made.  The  dura 
mater  is  often  yellow,  the  sinuses  engorged,  the  vessels  of  the  pia  con- 
gested, rarely  haemorrhage  in  the  subarachnoid  spaces  or  bloody  serum, 
the  cerebrum  not  abnormal,  the  ventricles  containing  a  little  serum, 
very  rarely  bloody  serum,  and  similar  conditions  in  the  spinal  canal, 
there  ■  being  nowhere  in  these  organs  any  evidences  of  inflammation. f 
On  the  other  hand,  inflammation  of  the  spinal  arachnoid  in  the  lumbar 
and  sacral  regions  has  been  reported,  but  the  constancy  of  such  lesions 
must  be  regarded  as  doubtful.  The  changes  which  have  been  observed 
in  the  coeliac  and  hepatic  plexuses,  and  which  consist  in  an  inflamma  ■ 
tion  of  the  neurilemma,  must  also  be  considered  as  of  doubtful  sig- 
nificance.J  More  or  less  congestion  of  the  lungs,  chiefly  hypostatic,  is 
usual,  and  the  bronchial  mucous  membrane  presents  the  usual  appear- 
ance of  passive  congestion.  The  sac  of  the  pericardium  contains  more 
or  less  serum,  as  a  rule,  and  it  is  rarely  bloody.  Purpuric  spots  are 
occasionally  seen  on  the  pericardium,  endocardium,  and  on  the  surface 
of  the  heart  itself.  The  muscular  tissue  of  the  heart  may  be  un- 
changed, but  it  is  very  often  more  or  less  softened  by  granular  de- 
generation. Various  changes  observed  in  the  composition  of  the 
blood  are  described,  but  thus  far  nothing  peculiar  to  yellow  fever  has 

*  This  question  is  most  elaborately  treated  by  La  Roche  ("  Yellow  Fever,"  vol.  ii), 
who  finds  the  arguments  against  contagion  stronger  than  those  in  favor, 

f  Lyons,  op.  cit.,  Appendix,  "  Pathological  Anatomy  of  the  Yellow  Fever  of  Lisbon," 
1851. 

jj.  "New  York  Medical  Journal,"  February,  1819.  Dr.  Schmidt  observed  important 
changes  in  the  semi-lunar  ganglion,  such  as  disappearance  of  the  nuclei  and  fatty  degen- 
eration. 


718  FEVERS. 

been  discovered.  It  is  true,  Dr.  Joseph  G.  Richardson,  of  Philadel- 
phia, supposed  he  had  found  a  peculiar  bacterium,  which  he  described 
as  bacterium  sanguinis,  in  the  blood,  but  other  competent  observers 
have  been  unable  to  confirm  his  observations.  A  rapid  crenation 
of  the  red-blood  corpuscles  has  been  noted  by  Dr.  Schmidt,*  of  New 
Orleans,  which  he  regards  as  a  retrogressive  change  probably  not 
peculiar  to  yellow  fever.  No  alterations  have  been  observed  in  the 
white-blood  corpuscles,  although  there  seemed  to  be  some  slight  increase 
in  their  relative  proportion.  The  most  characteristic  of  the  morbid 
alterations  of  yellow  fever  are  those  of  the  liver  and  other  abdominal 
organs.  In  the  Lisbon  epidemic,  in  the  epidemics  of  this  country, 
and  elsewhere,  the  liver  has  always  been  remarkably  altered.  Exte- 
riorly, it  most  usually  presents  a  fawn-yellow,  or  buff -color,  which  is 
pretty  uniform  throughout  the  whole  organ,  although  here  and  there 
may  be  patches  of  a  deeper  color.  Various  shades  of  the  above-de- 
scribed tint  are  observed  in  some  cases  and  in  different  epidemics, 
because  the  degree  to  which  the  alteration  has  attained  differs  some- 
what ;  but  when  the  ordinary  liver-brown  color  is  present,  on  minute 
examination,  the  liver  is  found  to  be  altered  in  the  usual  way.  The 
change  taking  place  in  the  liver  consists  of  a  fatty  infiltration,  and 
a  fatty  degeneration  of  the  protoplasm  of  the  hepatic  cells.  In  an 
advanced  case,  the  hepatic  cells  are  smothered  in  a  mass  of  fat-cells 
and  granules.  More  or  less  coloration  of  the  cells  about  the  radicles 
of  the  blood-vessels  with  blood  and  bile-pigments  is  to  be  seen.  The 
stomach-veins  are  deeply  engorged.  This  engorgement  may  be  gen- 
eral or  partial,  and  if  partial  the  mucous  membrane  about  the  cardiac 
extremity  is  chiefly  affected.  Patches  of  vascularity,  punctiform  con- 
gestion, ecchymoses,  and  purpuric  spots,  have  been  observed  in  different 
cases.  The  epithelium  is  usually  intact.  More  or  less  "  coffee-ground  " 
matter,  or  dark,  coffee-colored  liquid,  containing  coffee-grounds  mixed 
with  it,  is  found  in  the  stomach.  The  black  vomit  consists  chiefly 
of  blood  and  epithelium  ;  the  blood-corpuscles  are  deprived  of  their 
haemoglobin,  which  is  separate  ;  and  the  rest  is  made  up  of  white  cor- 
puscles, epithelial  cells,  and  debris.  The  spores  and  fully  developed 
yeast-plants  ( Torula  cerevisice)  are  found  in  the  vomited  matters,  and 
other  fungi  quickly  develop  in  them  on  standing.  The  mucous  mem- 
brane of  the  small  intestine  presents  the  same  deep  congestion  as  that 
of  the  stomach.  In  more  than  one  third  of  the  cases  in  the  Lisbon 
epidemic  there  was  present  in  the  intestine  extravasated  blood  in  various 
stages  of  the  alterations  produced  by  the  intestinal  juices,  and  which 
presented  an  inky  blackness,  a  reddish-brown  or  a  bloody  tint.  In  quan- 
tity the  extravasation  was  sufficient  to  distend  the  small  intestine  in 
some  instances,  and  was  generally  considerable.  The  glandular  appa- 
ratus of  the  small  intestine  has  been  usually  represented  as  intact  in 
"  New  York  Medical  Journal,"  February,  1879. 


YELLOW  FEVER.  719 

all  the  various  epidemics.  No  characteristic  changes  take  place  in  the 
spleen.  The  kidneys  are  rarely  normal.  A  considerable  hypera^mia 
of  these  organs  seems  to  be  nearly  constantly  present.  The  epithe- 
lium of  the  tubules  undergoes  granular  degeneration,  and  this  takes 
place  both  with  the  straight  and  convoluted  tubes.  Fatty  degenera- 
tion follows  in  those  cases  where  death  has  been  long  enough  postponed 
to  give  the  necessary  time.  The  urine  undergoes  important  altera- 
tions. The  uric  acid  and  urea  diminish  and  ultimately  disappear,  and 
are  replaced  by  leucin  and  tyrosin,  while  albumen  appears,  at  first  in  a 
mere  trace,  but  increasing  in  amount.  The  urine  also  assumes  a  deep 
color  from  the  quantity  of  blood-pigment  and  bile-pigment  present  in 
it,  and  is  denser  and  more  viscid  (Vidaillet*).  Schmidt  calls  attention 
to  changes  in  the  supra-renal  capsules,  but  they  do  not  seem  to  be  dif- 
ferent from  the  appearances  observed  in  numerous  maladies. 

Symptoms. — First  Stage. — The  period  of  incubation  varies  within 
wide  limits,  if  conclusions  are  drawn  from  exceptional  cases,  f  Usually, 
from  the  period  of  exposure  to  and  reception  of  the  disease-germ, 
from  one  to  three  days  will  elapse.  The  disease  begins  in  two  modes 
— one  with  prodromic  symptoms  or  gradually,  and  the  other  very  sud- 
denly. Soon  after  the  reception  of  the  poison,  in  many  subjects,  there 
ensue  impaii'ed  appetite,  a  feeling  of  debility,  headache,  muscular 
pains,  for  two  or  three  days,  when  the  disease  sets  in  with  a  chill,  or  a 
feeling  of  chilliness  followed  by  fever.  In  other  cases  there  are  no 
prodromal  or  premonitory  symptoms,  and  the  patient  is  seized  appar- 
ently while  in  full  health,  walking,  at  work,  asleep,  with  a  chill,  some- 
times a  severe  rigor,  and  the  fever  comes  on  immediately.  Very 
rarely  have  been  witnessed  in  recent  epidemics  those  formidable  cases 
in  which  the  patients  in  apparently  full  health  were  stricken  as  it  were 
with  a  heavy  bar  on  the  back,  falling  at  once  into  a  condition  of  pro- 
found prostration,  and  dying  collapsed  in  a  few  hours.  These  cases 
were  known  as  coup  de  barre,  or  stroke  of  the  bar,  because  of  the  in- 
tense violence  of  the  sudden  pain  in  the  back  and  loins.  In  every  epi- 
demic, however,  there  are  cases  characterized  by  profound  blood-poi- 
soning and  rapid  termination  in  collapse.  These  variations  will  be 
mentioned  presently.  Now  we  are  concerned  with  the  ordinary  course 
of  the  disease.  The  fever  rises  rapidly  and  reaches  its  maximum  on 
the  evening  of  the  first  or  second  day  (103°,  104°,  105°).  According  to 
the  tracings  of  Faget,  as  given  by  Sternberg, J  "in  sixteen  the  acme  is 
reached  on  the  first  day;  in  twenty-three  during  the  first  two  days  " — 
the  whole  number  of  observations  being  twenty-six.     The  onset  of  the 

*  "Archives  Generales  de  Medecine,"  November,  1869. 

f  La  Roche,  "Yellow  Fever,"  vol.  i,  p.  511,  Philadelphia,  1855. 

\  "  On  the  Nature  and  Duration  of  Yellow  Fever,  as  shown  by  Graphic  Temperature 
Charts  of  Typical  Cases,  etc.,"  "  The  American  Journal  of  the  Medical  Sciences,"  July, 
18'75,  p.  99.     By  Dr.  George  M.  Sternberg,  U.  S.  Army. 


720  FEVERS. 

disease  causes  great  disquiet,  and  the  victims  are  restless  and  disheart- 
ened. The  face  appears  anxious  and  flushed  ;  the  eyes  moist  and 
bright,  and  the  conjunctivae  injected.  There  are  decided  headache, 
throbbing  of  the  temples,  general  muscular  pains,  but  especially  severe 
and  depressing  pains  in  the  back  and  loins,  which  in  their  worst  form 
constitute  the  dreadful  coup  de  harre.  Early  in  the  disease,  and,  ac- 
cording to  some,  before  the  outbreak,  a  peculiar  odor  is  perceived,  and 
by  many  is  regarded  as  distinctive  of  yellow  fever.  The  odor  is  rather 
cadaveric  and  diffusible,  but  much  that  is  asserted  in  regard  to  it  seems 
to  the  author  very  apocryphal.  The  tongue  is  heavily  coated  with  a 
thick,  whitish  fur,  and  is  red  at  the  tip  and  edges,  the  swollen  papillae 
projecting  above  the  surface.  The  palate  mucous  membrane  becomes 
red  and  cedematous.  The  stomach  is  from  the  first  irritable  ;  the  epi- 
gastrium is  tender  to  the  touch  ;  cold  drinks  are  taken  with  great 
avidity,  excite  pain,  and  are  rejected  with  a  good  deal  of  painful  retch- 
ing at  first ;  and  the  stomach  is  equally  intolerant  of  all  kinds  of  food. 
Sometimes  there  is  diarrhcea,  but  usually  the  bowels  are  constipated. 
The  vomited  matters  at  this  early  stage  consist  of  particles  of  food, 
mucus,  and  bile,  and  flocculi  of  brownish  or  chocolate  colored  material 
— the  forerunner  of  the  dreaded  black  vomit.  The  stools  are  pasty  and 
grayish,  but  constipated.  The  urine  lessens  in  quantity,  darkens  in 
color,  and  distinct  traces  of  albumen  are  now  discovered  in  it.  The 
pulse  is  rapid,  strong,  with  high  tension  in  some  cases,  weak  and  di- 
crotic in  others,  and  the  pulsations  range  from  90  to  120.  When  the 
temperature  reaches  its  maximum,  usually  on  the  second  day,  it  begins 
to  decline  by  lysis,  a  remission  occurring  about  the  fourth  day,  ter- 
minating the  first  stage.  In  the  mildest  cases  the  remission  occurs  on 
the  second  day,  and  it  may  be  postponed  to  the  sixth  day  or  longer. 
During  the  period  of  maximum  temperature  and  the  first  stage,  besides 
the  symptoms  already  mentioned,  there  may  be  considerable  restless- 
ness and  active  delirium,  the  patient  being  kept  in  bed  with  difficulty, 
or  the  delirium  may  present  the  appearance  of  deliriutn  tremens — an 
active,  busy,  and  trembling  delirium.  At  this  stage  there  may  begin 
to  appear  a  jaundiced  tint  of  the  skin  ;  the  urine  may  contain  bile-pig- 
ment, the  stools  having  a  clay-color,  which  is,  however,  not  usual. 
There  may  also  occur  haemorrhages  from  the  nose,  from  the  gums, 
and  also  from  the  stomach  ;  but  it  is  only  in  the  severe  cases  that  these 
haemorrhages  occur  so  early,  and  hence  they  are  of  evil  augury. 

Second  Stage. — The  decline  of  temperature  which  marks  the  end 
of  the  first  stage  may  proceed  to  a  complete  intermission.  In  all  of 
the  cases  collected  by  Sternberg, "  a  complete  intermission,  or  nearly 
so,  was  found  on  the  morning  of  the  third  day."  According  to  others^ 
Haenish  for  example,  there  is  not  a  complete  defervescence — only  a 
remission — in  a  majority  of  the  cases.  With  the  decline  in  tempera- 
ture there   occurs  a  most  favorable   change  in  the  condition  of  the 


YELLOW  FEVER.  ^21 

patient.  The  delirium  subsides,  the  pains  cease,  the  stomach  may  be- 
come quiet,  some  critical  evacuation,  as  a  sweat,  an  attack  of  diarrhoea, 
or  an  epistaxis,  may  occur,  and  convalescence  be  at  once  established. 
Instead,  however,  of  these  favorable  symptoms  the  delirium  may  per- 
sist, the  irritability  of  the  stomach  may  increase,  albumen,  if  it  has  not 
been  in  the  urine,  may  now  appear,  the  pulse  may  become  weak,  and 
the  condition  of  the  patient  may  grow  rapidly  worse,  notwithstanding 
the  marked  defervescence  and  the  relief  to  the  symptoms  which  may 
at  first  be  caused  by  the  remission.  The  period  of  time  occupied  by 
the  remission  varies  considerably,  and  is  from  one  to  four  days. 

Third  Stage. — The  remission  disappears  and  the  temperature  rises 
again,  but  not  so  rapidly  as  during  the  first  stage,  the  maximum  of 
about  104°  being  reached  on  the  second  day.  If  the  active  delirium 
persists,  the  patient  becomes  unmanageable,  refuses  food  and  drink, 
the  leg-muscles  are  thrown  into  violent  cramps,  jaundice  deepens, 
black  vomit  comes  on,  the  pulse  fails  at  the  wrist,  and  death  closes  the 
scene  suddenly  in  the  midst  of  violent  delirium.  In  much  the  largest 
proportion  of  cases,  the  mind  is  unclouded,  and  the  moral  state  that  of 
complete  apathy  and  indifference.  The  strength  rapidly  declines,  and 
the  pulse  is  small,  weak,  and  irregular.  The  jaundice  passes  from  the 
characteristic  lemon-color  to  a  deep  mahogany,  and  haemorrhages  pom- 
out  from  the  various  mucous  surfaces  and  from  the  skin  ;  the  nose 
bleeds,  and  blood  is  vomited,  passed  by  stool,  and  less  often  expec- 
torated. The  gums  are  soft,  spongy,  and  bleed  with  a  touch,  and 
rarely  the  ears  bleed.  The  most  striking  and  characteristic  phenom- 
enon is  the  haemorrhage  into  the  stomach  and  the  return  of  the  blood 
in  the  form  of  '"  black  vomit."  Even  during  the  first  stage,  small 
flocculi,  of  a  chocolate-color  and  composed  of  altered  blood,  are  seen  in 
the  vomited  matters,' but  the  "coffee-grounds  "  do  not  appear  usually 
until  the  second,  or  stage  of  remission,  and  often  indeed  not  until  the 
third  stage.  The  urine  constantly  lessens  in  amount ;  the  urea  disap- 
pears ;  blood-pigment  distills  through  in  large  quantity ;  the  albumen 
increases,  and  very  soon,  in  some  cases,  entire  suppression  occurs. 
Under  these  circumstances,  somnolence,  stupor,  and  ultimately  coma 
supervene.  Partial  convulsions,  hiccough,  and  Cheyne-Stokes  breathing 
are  often  observed  in  these  uraemic  cases.  The  temperature  also  great- 
ly declines  toward  the  end — to  100°  even  ;  and  it  is  a  curious  fact  that 
the  action  of  the  heart  continues  for  a  time  after  the  respiration  and 
pulse  at  the  wrist  have  ceased.  If  the  case  take  a  favorable  turn  dur- 
ing the  third  stage,  the  temperature  descends  to  normal  very  abruptly, 
and  an  improvement  in  the  condition  of  the  patient  at  once  occurs. 
The  vomiting  stops,  and  a  little  aliment  may  be  taken  ;  the  kidneys 
act  freely,  the  circulation  improves,  and  very  gradually  convalescence 
is  established. 

Course,  Duration,  and  Termination. — There  are  several  forms  of 
46 


722  FEVERS. 

yellow  fever,  which  differ  sufficiently  to  require  some  special  consider- 
ation. Many  divisions  have  been  made,  but  in  the  following  forms  are 
comprehended  the  most  important  varieties — the  algid,  the  sthenic,  the 
hsemorrhagic,  the  purpuric,  the  typhous  (Lyons).  The  purpuric  foi-m 
is,  however,  only  the  hsemorrhagic  modified.  Excluding  this,  we  have 
four  varieties  of  the  disease,  capable  of  ready  clinical  distinction.  The 
algid  form  occurs  in  subjects  debilitated  by  want  and  misery.  The 
surface  is  cold,  the  face  sunken  and  of  a  livid  hue,  the  extremities  blue, 
cold,  and  shrunken,  the  skin  covered  with  purpuric  patches,  the  pulse 
small  and  feeble,  the  temperature  in  the  axilla  at  96°  Fahr.  Such 
symptoms  are  not  present  merely  at  the  outset,  but  continue  to  the 
end.  Black  vomit  occurs  early,  and  the  hsemoiThages  take  place  from 
all  the  mucous  surfaces.  In  the  sthenic  form,  the  opj)osite  conditions 
prevail.  The  robust,  at  the  prime  of  life,  are  the  subjects.  High 
fever,  severe  headache  and  lumbar  pain,  delirium  of  an  active  kind, 
early  jaundice,  having  the  lemon-tint,  and  less  of  the  black  vomit,  are 
the  most  characteristic  features  of  this  form.  In  the  hmmorrhagic 
form,  the  peculiarity  consists  in  profuse  and  simultaneous  discharges 
of  blood,  effused  at  various  points.  Black  vomit  and  intestinal  haem- 
orrhage, uterine  and  renal  haemorrhage,  simultaneous  bleeding  from 
the  eyes,  nose,  ears,  and  mouth,  and  effusion  of  blood  from  any  acci- 
dental abrasion,  give  to  this  form  a  distinct  individuality.  In  the 
typhous  form  are  presented  symptoms  which  ally  these  cases  to  other 
typhous  processes.  They  are  characterized  by  stupor,  prostration, 
sunken  countenance,  suffused  eyes,  dorsal  decubitus,  low-muttering 
delirium,  in  addition  to  the  usual  and  ordinary  symptoms  of  the  dis- 
ease. The  mortality  from  yellow  fever  is  largely  influenced  by  the 
type  of  the  prevailing  epidemic,  and  also  by  the  local  conditions,  and 
by  the  form  of  the  seizure,  whether  algid,  hsemorrhagic,  sthenic,  or 
typhous.  It  necessarily  varies  much,  and  between  such  wide  limits  as 
from  fifteen  to  eighty  per  cent.  More  men  die  than  women  and  chil- 
dren. The  habits  of  the  individual  as  to  temperance  enter  seriously 
into  the  prognosis,  since  the  mortality  among  spirit-drinkers  is  very 
high.  All  circumstances  which  act  to  depress  the  vital  forces  increase 
the  severity  of  an  attack.  The  early  occurrence  of  black  vomit  and 
suppression  of  urine  are  very  ominous  symptoms. 

Diagnosis. — The  only  disease  with  which  yellow  fever  is  likely  to 
be  confounded  is  remittent  fever  with  jaundice.  The  distinction  rests 
on  the  temperature  line  and  the  occurrence  of  black  vomit.  The  re- 
missions of  malarial  fever  are  quotidian  or  tertian,  and  the  fever  of  the 
first  stage  of  yellow  fever  is  continued  until  the  defervescence.  No- 
thing like  black  vomit  occurs  in  malarial  fever  ;  while  remittent  fever 
is  promptly  broken  up  by  eflicient  doses  of  quinia,  this  remedy  has  no 
influence  on  yellow  fever.  Again,  remittent  fever  prevails  much  more 
widely  than  yellow  fever.      It  is  only  within  the  yellow-fever  zone 


YELLOW  FEVER.  Y23 

that  a  question  of  differentiation  can  arise.  When  an  epidemic  influ- 
ence is  at  work,  there  can  be  no  difliculty  in  the  diagnosis  after  the 
first  cases  have  appeared. 

Treatment. — It  is  good  practice  to  begin  the  treatment  by  a  mercu- 
rial purgative  ;  a  half-grain  of  calomel  two  or  three  times  on  the  first 
day,  followed  by  a  warm-water  enema.  All  drastic  cathartics  should 
be  avoided,  owing  to  the  irritable  state  of  the  stomach.  If  the  pain  in 
the  back  and  loins  is  very  severe,  one  twelfth  of  a  grain  of  morphia 
should  be  administered  hypodermatically,  and  repeated  according  to 
circumstances.  For  the  irritable  stomach,  there  are  two  most  efficient 
remedies,  carbolic  acid,  and  lime-water  with  milk — a  fourth  of  a  grain 
of  carbolic  acid  in  some  mint-water  every  two  hours,  and  a  tablespoon- 
ful  of  lime-water  and  milk,  equal  parts,  every  two  hours,  so  that  these 
remedies  will  be  taken  in  alternation  every  hour.  Ice  should  be  kept  in 
the  mouth  and  small  pieces  swallowed,  but  care  is  necessary  to  avoid  dis- 
tention of  the  stomach.  For  the  epigastric  tenderness,  mustard  should 
be  applied,  and,  if  the  patient  is  vigorous  and  the  reaction  sthenic, 
leeches  or  cups  should  be  used.  During  the  second  stage,  for  the  irri- 
table stomach  a  little  dry  champagne  is  often  very  serviceable,  as  it  is 
very  grateful.  Hydrocyanic  acid,  and  especially  chlorodyne,  may  also 
act  well  as  sedatives  to  the  stomach.  If  the  fever  is  high,  the  skin  hot 
and  mordicant,  the  wet  pack  may  be  used  with  advantage,  or  the  body 
may  be  sponged  over  and  then  rubbed  with  some  animal  fat,  as  lard 
or  suet,  several  times  a  day.  The  temperature  may  be  reduced  further 
by  the  rectal  injection  of  a  scruple  of  quinine,  but  this  agent  should 
not  be  administered  by  the  stomach,  as  it  will  surely  excite  vomiting. 
For  the  same  reason  all  harsh  and  drastic  or  irritating  medicines 
should  be  avoided.  The  delirium  and  obstinate  wakefulness  of  some 
cases  require  morphia  and  atropia  (the  latter  in  small  proportion)  hy- 
podermatically. When  the  delirium  is  active,  the  patient  restless  and 
difficult  to  control,  the  most  efficient  hypnotic  and  calmative  is  duboi- 
sia,  given  subcutaneously  {^-^  grain)  ;  Aitken  suggests  chlorodyne. 
As  digestion  is  almost  entirely  suspended,  it  is  useless  to  push  beef -tea 
and  milk  when  the  stomach  rejects  everything.  The  best  aliment  is 
milk  and  lime-water,  half  and  half,  given  in  small  quantity,  not  to 
exceed  a  tablespoonf  ul  every  two  hours.  If  curds  are  thrown  up  in 
hard  masses,  the  quantity  of  milk  is  too  great.  Thin  barley-water  to 
which  some  milk  is  added,  and  then  diluted  with  lime-water,  is  a  suita- 
ble aliment.  During  the  stage  of  convalescence,  the  utmost  circumspec- 
tion is  necessary  in  giving  aliments.  The  algid  form  of  yellow  fever 
requires  stimulants  from  the  beginning.  In  the  hsemorrhagic  form, 
small  doses  of  turpentine  and  tincture  of  the  chloride  of  iron  should  be 
given  frequently.  In  the  sthenic  form,  the  wet  pack,  leeches,  quinia, 
morphia,  and  duboisia,  are  the  most  appropriate  remedies.  In  the 
typhous  form,  suitable  aliment,  wine,  and  the  stronger  stimulants  are 


724  FEVERS. 

required.  Yellow-fever  patients  should  be  isolated.  All  of  the  dejec- 
tions by  vomit  or  stool  should  be  at  once  disinfected.  The  room  and 
halls  should  be  fumigated  with  sulphurous  acid.  All  articles  of  cloth- 
ing and  bedding  about  the  patient  should  be  destroyed,  or  put  into 
boiling  water  and  boiled  before  handling.  Questions  of  quarantine  are 
not  included  in  the  scope  of  this  work. 


DENGUE. 

Definition. — Dengue  *  is  an  acute  febrile  disease  which  prevails  as 
an  epidemic,  and  is  characterized  by  two  paroxysms  of  fever,  with  an 
intermission  of  variable  duration  between  them,  the  first  paroxysm 
being  accompanied  by  high  fever  and  joint  swellings,  and  an  eruption, 
the  second  subsiding  suddenly  with  some  critical  evacuation.  It  is 
also  called  "  break-bone  fever,"  "  dandy  fever,"  "  neuralgic  fever,"  etc. 

Causes. — There  are  close  analogies  between  dengue  and  relapsing 
fever  ;  indeed  dengue  is  a  relapsing  fever.  It  occurs  as  an  epidemic, 
and  attacks  a  large  part  of  the  population  among  whom  it  appears. 
Apparently  beginning  on  this  continent,  or  in  the  West  India  Islands, 
it  has  spread  to  most  of  the  warm  countries  of  the  globe,  following  the 
routes  of  human  intercourse.  Rush,  one  of  the  first  to  give  an  ac- 
count of  it,  mentions  it  as  occurring  in  Philadelphia  in  1780.  It  is  not 
generally  regarded  as  contagious,  although  maintained  to  be  by  Dick- 
son, f  and  some  others.  A  peculiar  condition  of  the  atmosphere  seems 
necessary,  the  epidemics  occurring  after  prolonged  high  temperature 
(Dickson),  or  great  heat  and  moisture  combined  (Aitken  J).  It  has 
been  observed  in  several  epidemics  that  the  attacks  of  dengue  suc- 
ceeded to  epidemics  of  scarlet  fever,  of  yellow  fever,  and  of  whooping- 
cough.  The  disease  occurs  in  all  ages  and  in  both  sexes,  but  the  negro 
race  seems  to  be,  although  not  exempt,  somewhat  less  susceptible, 
while  the  mulattoes  are  attacked  equally  with  whites. 

Symptoms,  Course,  Duration,  and  Termination. — There  may  or  may 
not  be  a  prodromal  or  preliminary  stage.  The  period  of  incubation  is 
in  some  instances  "  prodigiously  brief "  (Dickson),  the  attacks  in  any 
given  household  occurring  so  nearly  simultaneously  that  all  are  sick 
at  the  same  time.  Toward  the  end  of  an  epidemic  the  period  which 
elapses  after  exposure  may  be  lengthened  to  five,  even  to  ten  days. 
When  the  epidemic  is  at  the  maximum,  the  attack  may  follow  exposure 
with  in  afew  hours  and  the  disease  occur  promptly  without  any  pre- 
liminary symptoms.  When  prodromes  occur  they  consist  of  weariness, 
lassitude,  headache,  anorexia,  a  white  tongue,  and  more  or  less  general 

*  The  word  dengue  is  pronounced  dangay. 

f  Fenner's  "  Southern  Medical  Reports,"  vol.  ii,  p.  384,  "  A  History  of  the  Epidemic 
Dengue  as  it  prevailed  in  Charleston  in  the  Summer  of  1850." 
X  Reynolds's  "  System,"  vol.  i,  p.  98,  American  edition. 


DENGUE.  725 

soreness  of  the  body.  Usually,  however,  the  onset  of  the  disease  is 
sudden.  The  patient  is  taken  in  full  health,  often  waked  out  of  sleep, 
with  intense  headache,  burning  pain  in  the  temples,  backache,  and 
severe  aching  of  all  the  joints,  including  the  fingers  and  toes.  Some- 
times the  initial  symptom  is  an  acute  pain  in  the  knees,  ankles,  and 
wrists,  the  patient  being  seized  while  walking.  General  muscular  stiff- 
ness follows,  so  that  the  affected  members  become  useless,  and  any 
attempt  to  move  the  joints  causes  severe  suffering.  With  the  head- 
ache there  is  also  great  intolerance  of  light  and  sound.  The  face  is 
flushed  and  hot ;  the  tongue  coated  ;  a  good  deal  of  burning  pain  is 
felt  in  the  abdomen ;  there  are  nausea  and  vomiting,  during  which  a 
quantity  of  bilious  matter  comes  up,  and  scarcely  anything  is  retained  ; 
constipation  persists  ;  the  action  of  the  heart  is  rapid,  the  pulse  strong, 
and  beating  at  140  or  higher  in  children.  Sometimes  also,  espe- 
cially in  children,  there  is  delirium,  and,  in  very  young  children,  the 
onset  of  the  disease  may  be  marked  by  convulsions  (Dickson).  An 
exanthem  of  very  variable  character,  but  most  frequently  scarlati- 
niform,  may  appear,  and  hence  the  frequent  confounding  by  the 
older  authors  of  this  disease  with  scarlatinal  rheumatism.  The 
duration  of  the  first  febrile  stage  is  very  variable,  lasting  from  six 
hours  to  several  days.  It  may  cease  rather  suddenly  with  critical  phe- 
nomena, or  slowly  by  lysis.  The  decline  of  the  fever  is  signalized  by 
the  disappearance  of  the  eruption  if  it  had  existed,  by  the  appearance 
of  moisture  on  the  skin,  a  profuse  urinary  discharge,  an  attack  of  diar- 
rhoea, the  stools  being  dark  and  offensive  (Aitken),  and  by  the  subsi- 
dence of  the  headache  and  joint-pains.  Usually,  at  the  termination  of 
the  remission,  the  patient  is  in  a  condition  of  very  considerable  pros- 
tration, and,  although  much  relieved,  is  unable  to  leave  his  bed.  In 
other  cases,  the  relief  is  so  great  and  the  strength  so  well  preserved 
that  the  patient  insists  on  getting  up.  The  remission  may  not  occur 
at  all.  In  those  cases  the  joint  affection  appears  with,  and  the  erup- 
tions after,  the  first  symptoms;  the  fever  is  continuous,  and  lasts  from 
five  to  ten  days,  when  it  disappears  with  critical  phenomena.  It  is  by 
no  means  improbable  that  a  distinct  remission  of  short  duration  occurs, 
but  escaped  the  observation  of  practitioners  unprovided  with  the  means 
of  accurate  investigation.  The  duration  of  the  remission  or  intermis- 
sion is  not  constant,  and  varies  from  a  few  hours  to  two  or  four  days. 
During  the  period  of  remission  there  are  more  or  less  headache  and 
soreness,  and  stiffness  of  the  joints  and  muscles,  notwithstanding  a 
very  great  diminution  in  the  severity  of  these  symptoms  ;  hence  it  may 
be  concluded  that  the  condition  of  the  interval  is  rather  that  of  remis- 
sion than  intermission.  At  the  conclusion  of  this  interval,  whether  of 
several  hours'  or  two  or  four  days'  duration,  the  symptoms  begin  again : 
the  fever  rises,  although  not  so  high  as  during  the  first  stage  ;  the 
headache,  some  muscular  soreness,  but  only  occasionally  the  swollen. 


Y26  FEVERS. 

red,  and  painful  joints,  are  felt  again  ;  the  tongue  becomes  coated 
anew,  the  appetite  ceases,  and  more  or  less  nausea,  very  rarely  vomit- 
ing, is  experienced,  The  distinctive  peculiarity  of  the  second  period, 
however,  is  the  occurrence  of  an  exanthem — erythematous,  roseola- 
like, rubeolous,  lichenoid,  etc.  Usually,  beginning  as  an  efflorescence 
on  the  palms  of  the  hand  and  soles  of  the  feet,  it  spreads  thence  over 
the  body.  It  is  often  accompanied  by  intense  itching.  The  eruption 
may  be  distinctly  localized  to  particular  parts  of  the  body.  The  dura- 
tion \>i  the  eruption  is  variable,  lasting  from  several  hours  to  two  or 
three  days,  and  terminates  by  desquamation  of  the  f urfuraceous  kind. 
The  subsidence  of  the  second  stage  is  gradual,  and  the  patients  are  left 
in  a  feeble  state,  requiring  months  for  complete  restoration.  There 
may  occur  other  relapses.  The  joints  continue  stiff  and  sore  for  a  long 
time.  It  is  not  surprising  that  persons  attacked  with  dengue  should 
be  much  reduced.  The  fever,  severe  pains,  loss  of  sleep,  inability  to 
take  food,  the  critical  evacuations,  and  the  relapses,  are  sufficient  to  tax 
severely  the  vital  resources  of  the  most  robust  patient.  It  is  never 
fatal  in  adults,  and  it  is  rarely  that  children  die  in  convulsions.  It  is 
a  disease  without  complications,  and  leaves  behind  no  sequelae.  The 
whole  duration  of  fully  developed  cases  is  about  eight  days,  of  which 
the  first  stage  occupies  three  days,  the  intermission  two  days,  and 
the  last  stage  three  days  or  nearly  so,  but  the  period  of  convalescence 
may  be  protracted  over  several  weeks,  because  of  the  weakness,  emaci- 
ation, and  lingering  joint  swelling  and  pain,  and  relapses  may  several 
times  take  place,  still  further  retarding  recovery. 

Treatment. — As  dengue  is  a  specific  disease  for  which  we  have  no 
specific  remedy,  it  must  be  treated  symptomatically,  or  in  accordance 
with  empirical  observation.  During  several  epidemics  the  use  of 
emetics,  carried  to  the  point  of  free  bilious  evacuations,  was  followed 
by  decided  amelioration  of  all  the  symptoms.  Next  to  the  emetic  in 
importance  is  an  efficient  but  mild  laxative.  The  substitution  of  more 
healthy  evacuations  for  the  greenish,  tarry,  offensive  stools  has  also 
had  a  good  effect  on  the  progress  of  the  disease.  Anodynes  are  needed 
to  relieve  the  severe  pains.  It  is  probable  that  salicylic  acid  will  have 
a  decided  influence  over  the  rheumatic  symptoms,  which  are  such  prom- 
inent features  of  the  malady.  If  salicylic  acid  or  the  salicylates  fail, 
antipyretic  doses  of  quinia  should  be  tried.  It  is  important  to  main- 
tain free  action  of  the  organs  of  excretion ;  hence,  if  the  pain  is  so 
severe  as  to  demand  the  administration  of  morphia,  the  bowels  should 
be  kept  open  and  the  kidneys  active.  As  the  first  stage  terminates 
with  some  critical  evacuation,  often  with  a  sweat,  the  behavior  of  na- 
ture may  possibly  be  imitated  and  the  paroxysms  shortened  by  the 
administration  of  pilocarpine.  The  intolerable  itching,  so  often  pres- 
ent, may  be  allayed  by  sponging  over  the  part  a  one  per  cent,  solution 
of  carbolic  acid.    'The  joint-pains  and  soreness  of  the  muscles  remain- 


CHOLERA.  Y27 

ing  during  convalescence  may  be  removed  by  the  application  of  gal- 
vanism. Tincture  of  chloride  of  ii'on  is  the  most  useful  chalybeate  to 
be  given  in  convalescence.  To  restore  appetite  and  digestion,  tincture 
of  nux  vomica  will  be  found  efficient,  or  a  combination  of  dilute  phos- 
phoric acid,  pyrophosphate  of  iron,  and  strychnia  may  be  administered. 


MIASMATIC  DISEASES. 


CHOLERA. 


Definition. —  Cholera  is  an  acute  infectious  disease,  endemic  in  some 
localities,  epidemic  elsewhere,  and  characterized  by  vomiting  and  purg- 
ing of  a  peculiar  rice-water-like  fluid,  and  a  condition  of  collapse  and 
death,  or  of  a  reaction  from  collapse  and  the  development  of  a  typhoid 
state.  It  is  known  also  as  epidemic  cholera,  Asiatic  cholera,  malignant 
cholera,  etc. 

Causes. — The  etiological  factors  concerned  in  the  diffusion  of  chol- 
era are  very  complex.  Is  there  a  cholera-germ  ?  The  facts  thus  far 
accumulated  render  it  highly  probable  that  cholera  is  propagated  by  a 
minute  organism — a  protomycete — but  all  the  attempts  at  selection 
and  cultivation  have  thus  far  proved  abortive,  and  in  this  statement 
we  include  the  experiments  of  Thiersch.  Although  the  cholera-germ 
has  not  been  isolated,  the  theory  which  assumes  its  existence  best  recon- 
ciles all  the  facts,  and  we  therefore  provisionally  adopt  it  until  the  real 
cause  or  morbific  principle  is  discovered.  When  the  first  epidemics 
of  cholera  started  on  their  march  around  the  world,  they  pursued  a 
general  direction  from  east  to  west,  following  the  routes  of  com- 
merce, and  from  one  great  center  of  population  to  another,  but  this 
course  was  not  inevitable  from  the  nature  of  the  poison,  and  it  is  now 
known  that  the  disease  pursues  no  defined  course,  and  in  fact  spreads 
in  all  directions,  according  to  the  freedom  of  communication.  It  is 
conveyed  by  caravans,  by  ships,  in  clothing,  baggage,  and  other  effects, 
by  streams  of  water,  by  air,  etc.  It  is  not  contagious,  in  the  common 
acceptation  of  that  term.  Physicians  and  attendants  in  cholera  hos- 
pitals are  not  more  exposed  than  others,  during  the  existence  of  the 
epidemic,  unless  a  local  source  of  infection  occurs.  The  author  had 
charge  of  the  cholera  hospital  in  Cincinnati  during  the  epidemic  of 
1866,  and  not  only  visited  the  wards  several  times  daily,  but  made  a 
number  of  autopsies,  and  on  several  occasions  was  wounded,  without 


728  MIASMATIC   DISEASES. 

experiencing  the  first  symptom  of  the  disease.  The  assistant  physicians 
and  attendants  were  equally  exempt.  The  dead  bodies  of  cholera  sub- 
jects apparently  possess  no  infective  property.  The  bacteria  of  de- 
composition destroy  the  disease-germs  of  cholera.  The  morbific  ma- 
terial or  germ  is  more  certainly  conveyed  in  the  moist  state,  and  some 
preparation  or  transformation  must  be  undergone  before  it  becomes 
active.  As  it  leaves  the  person  of  the  sick  it  does  not  appear  to  have 
toxic  power,  but  acquires  this  subsequently.  Hence  cholera  is  not 
communicated  directly  from  one  person  to  another  :  an  intermediate 
condition  of  preparation  is  necessary.  Hence  the  importance  of  the 
superficial  water-supply  (the  ground-water  of  Pettenkof  er),  and  of  cer- 
tain geological  formations.  The  character  of  the  soil  best  adapted  to 
the  nurture  of  cholera-germs,  because  retentive  of  the  surface-water, 
is  alluvium,  light  and  porous,  resting  on  an  impervious  clay  subsoil. 
Malarial  regions  are  generally  very  favorable  to  the  growth  of  cholera- 
germs.  When  the  ground-water  is  low,  the  germs  are  produced  in 
greater  abundance  than  when  it  is  high.  Cholera  is  always  spread 
rapidly  when  the  drinking-water  is  supplied  from  the  surface  drainage, 
and  hence  is  rich  in  organic  matter.  The  records  of  cholera  epidemics 
are  full  of  most  striking  examples  of  this  truth.  The  excretions  of 
cholera  patients,  thrown  on  the  ground,  or  into  superficial  j^^i^y- 
vaults,  quickly  reach  the  ground-water,  multiply  rapidly,  and  soon  the 
sources  of  water-supply,  the  suj)erficial  wells  and  streams,  become  con- 
taminated. Hence  it  is  that  one  of  the  principal  sources  of  cholera  in- 
fection is  the  water-supply.  When  an  epidemic  influence  prevails,  not 
all  exposed  to  the  poison  contract  the  disease  ;  great  differences  in  the 
individual  susceptibility  are  found  to  exist.  The  hygienic  influences 
affecting  the  individual  are  highly  important.  Excesses  in  venery,  in 
spirit-drinking,  late  hours,  and  an  irregular  life  generally,  bad  air,  and 
moral  depression  and  fear  of  the  disease,  exercise  an  unfavorable  influ- 
ence. Males  are  more  apt  to  have  cholera  than  females,  and  infants 
are  less  susceptible.  The  mortality  is  less  among  children  than  among 
adults,  and  is  greatest  between  twenty  and  thirty.  Although  it  is  true 
that,  heat  favors  the  spread  of  cholera,  and  that  the  greatest  mortality 
is  during  the  hot  season,  yet  it  does  prevail  during  the  winter  ;  a  nota- 
ble example  was  afforded  by  the  Russian  epidemic  of  the  winter  of 
1830-'31.  The  disposition  to  an  attack  of  cholera  seems  greatest  in 
the  early  morning.  A  hot,  moist,  and  stagnant  atmosphere  is  especially 
favorable  to  the  development  of  the  epidemic  influence.  A  light  rain- 
fall, followed  by  a  warm  mist,  the  air  being  still,  was  the  condition  of 
the  atmosphere  when  the  cholera  assumed  its  most  severe  phase  in  the 
Cincinnati  epidemic*    An  ordinary  epidemic,  under  the  circumstances 

*  A  "  norther,"  with  rain,  preceded  a  fearful  outbreak  of  cholera  among  the  United 
States  troop8  (Eighth  Infantry)  at  Lavacca,  Texas.  Reported  by  Dr.  N.  S.  Jarvis, 
U.  S.  A.,  Fenner's  "  Southern  Hospital  Reports,"  vol.  i,  p.  436,  et  seq.,  1849. 


CHOLERA.  Y29 

of  its  introduction  in  one  of  our  cities,  is  not  likely  to  prevail  longer 
than  two  months.  July,  August,  and  September  are  the  months  of 
greatest  prevalence  of  the  epidemic,  as  a  rule.  From  the  period  of 
exposure  and  reception  of  the  poison  until  the  outbreak  of  the  disease 
— the  incubation — from  two  to  four  days  usually  elapse.  But  this  is 
not  a  fixed  and  invariable  period — it  may  extend  to  one  or  two  weeks, 
but  very  rarely  longer.  Healthy  persons,  arriving  in  an  infected  city, 
are  attacked  in  from  three  to  four  days.  "When  the  germs  of  disease 
are  brought  to  a  healthy  city,  about  a  week  elapses  before  cases  of  the 
disease  appear. 

Pathological  Anatomy. — If  death  has  occurred  in  the  asphyxia,  the 
stomach  contains  more  or  less  of  the  whey-like  material  of  the  cholera- 
discharges — a  material  alkaline  in  reaction,  albuminous,  and  full  of 
cast-off  epithelium.  Later,  or  during  reactionary  fevei',  the  mucous 
membrane  is  congested,  and  marked  by  extravasations  and  ecchymoses. 
The  small  intestines  usually  contain  a  large  quantity  of  the  whey-like 
fluid,  full  of  epithelium.  The  glands  of  Brunner,  the  solitary  and 
agminated  patches  are  thickened  and  very  prominent.  The  villi  of  the 
mucous  membrane,  as  well  as  the  epithelium,  are  stripped  off,  leaving 
the  basement  membrane  for  the  most  part  bare.  The  solitary  glands 
of  the  large  intestine  are  also  infiltrated  and  swollen.  Sometimes  the 
colon  is  the  seat  of  a  diphtheritic  process,  but  this  is  a  change  pertain- 
ing to  the  fever  of  reaction.  The  spleen  is  small,  wrinkled,  and  firm 
during  asphyxia,  but  in  the  secondary  fever  it  enlarges  and  is  softer. 
The  biliary  passages  contain  a  quantity  of  cast-off  epithelium,  which 
probably  obstructs  the  outflow  of  bile — for  usually  the  gall-bladder  is 
well  distended  with  a  rather  thick,  viscid  bile.  The  liver  is  more  or 
less  advanced  in  fatty  degeneration,  but  is  not  conspicuously  altered, 
although,  by  reason  of  changes  in  the  hepatic  cells  in  spots,  the  organ 
may  present  a  somewhat  mottled,  yellowish  discoloration,  mixed  with 
brown.  The  changes  in  the  kidneys  are  of  the  same  nature  as 
those  of  other  mucous  surfaces.  The  epithelium  of  the  tubules  is 
granular,  cloudy,  and  is  detached  from  the  basement  membrane,  block- 
ing the  tubes,  so  that  the  whole  organ  has  the  appearance  of  the 
pale,  smooth,  white  kidney.  Here  and  there,  however,  there  are  spots 
of  injection,  and  occasional  patches  of  ecchymosis.  The  bladder  is 
empty  and  contracted,  or  contains  a  very  little  milky  urine.  The  peri- 
toneum is  dry,  sticky,  from  the  presence  of  a  quantity  of  loose  epithe- 
lium still  adherent,  and  hence  the  membrane  does  not  present  the 
transparent  and  glistening  appearance  of  health.  The  pleura  presents 
the  same  conditions  :  its  transparency  is  impaired,  it  is  adhesive,  and 
the  epithelium  is  cast  off  in  great  quantity.  The  lungs  are  deeply  con- 
gested, especially  posteriorly  ;  ecchymoses  of  the  bronchial  mucous 
membrane  and  infarctions  of  the  lungs  are  occasionally  encountered. 
The  great  venous  trunks  and  the  right  cavities  of  the  heart  are  dis- 


730  MIASMATIC   DISEASES. 

tended  with  blood,  while  the  left  cavities  are  empty  and  contracted. 
The  blood  is  dark,  almost  black  in  color,  thick  and  viscid,  feebly  coag- 
ulable,  and  sometimes  incoagulable.  The  pericardium  is  dry,  and 
there  are  numerous  ecchymoses  on  the  visceral  layer.  The  muscular 
tissue  of  the  heart  is  not  affected.  There  are  but  few  changes  in  the 
brain.  The  author  observed,  in  all  of  his  autopsies,  considerable  hy- 
peraemia  and  dilatation  of  the  vessels  of  the  medulla  oblongata.  The 
constancy  of  this  lesion  would  seem  to  indicate  a  relationship  between 
congestion  of  the  medulla  and  the  cramp. 

Symptoms. — First  or  Prodromal  Stage. — As  there  are  two  forms 
of  disease  from  which  cholera  may  proceed,  although  they  are  quite 
independent  affections  under  other  circumstances,  they  may  be  with 
propriety  regarded  as  modes  of  manifestation  of  cholera-poisoning. 
These  maladies  are  diarrhoea  and  cholerine.  During  every  epidemic 
of  cholera,  a  large  proportion  of  cases  set  in  by  a  diarrhoea,  which  if 
permitted  to  continue  will  develop  into  a  typical  attack  of  cholera. 
Others  begin  as  a  cholerine,  with  vomiting  and  purging  like  an  ordi- 
nary cholera  morbus,  and  if  uncontrolled  the  case  assumes  the  charac- 
teristics of  cholera.  Cholera-diarrhoea  may  arise  from  ordinary  causes 
— from  taking  cold,  errors  of  diet,  etc.  There  is  some  chilliness, 
thirst  is  exacting,  the  tongue  is  pasty,  and  there  is  a  bitter  or  mawkish 
taste.  Some  pain  may  be  felt  in  the  abdomen,  but  the  stools  pass 
with  ease,  are  copious  and  watery,  and  cause  a  decided  feeling  of 
weakness.  There  may  be  no  more  than  two  or  three  stools  in  the 
course  of  the  day,  but  the  failure  of  strength  is  remarkable  and  quite 
out  of  proportion  to  the  loss  of  material.  Such  a  diarrhoea  may  in  a 
day  or  two  become  very  profuse,  the  stools  whey-like,  cramps  in  the 
legs,  cold  tongue,  cold  breath,  toneless  voice,  suppression  of  urine 
come  on,  and  the  patient  pass  into  cholera  asphyxia.  During  a  cholera 
epidemic  there  is  danger  that  every  case  of  diarrhoea  may  assume 
cholera  characteristics.  It  has  usually  been  observed  that  during  a 
cholera  epidemic  there  is  a  general  prevalence  of  diarrhoea,  or  such  a 
state  of  relaxation  of  the  bowels  that  a  laxative  causes  drastic  effects. 
Cholerine  behaves  as  an  ordinary  attack  of  cholei-a  morbus,  except 
that  the  discharges  have  less  and  less  of  the  stomachal  and  fecal 
characters,  that  cramps  are  more  apt  to  occur,  and  that  the  symp- 
toms of  cholera  asphyxia  readily  come  on.  In  many  epidemics  pro- 
dromes have  been  observed.  The  author  has  seen,  in  most  cases, 
mental  depression,  fatigue  of  body,  and  chilliness  precede  the  regular 
attack.  On  the  other  hand,  a  feeling  of  recklessness,  or  apathy  and 
indifference,  has  been  noticed.  In  all  cases  diarrhoea  or  cholerine  has 
ushered  in  the  attack.  The  characteristics  of  the  diarrhoea  have  been 
copious,  watery,  rapidly  becoming  whey-like  stools,  passed  easily,  with 
force,  and  without  pain.  A  majority  of  patients  are  attacked  after 
midnight  and  toward  morning.     If  there  had  been  no  diarrhoea  the 


CHOLERA.  731 

day  before,  which  is  rather  exceptional,  the  patient  is  waked  with  an 
urgent  desire  to  go  to  stool,  and  he  at  once  passes  an  ordinary  diar- 
rhoea stool  of  great  volume,  and  the  first  is  quickly  followed  by  others, 
even  more  copious  and  assuming  a  lighter  color.  If  diarrhoea  has 
existed  during  the  previous  day,  the  first  stool  is  of  a  whitish  color. 

Second  Stage. — With  the  large  evacuations  which  announce  the 
onset  of  the  regular  cholera  attack,  there  is  a  marked  degree  of  chilli- 
ness, anxiety,  and  alarm,  but  with  many  an  absolute  indifference.  The 
evacuations  come  w^th  a  rushing  force  and  amount  to  quarts  of  gray- 
ish, or  whitish,  rice-water  or  whey-like  fluid.  The  patient  feels  cold, 
weak,  and  dizzy,  and  is  glad  to  throw  himself  on  the  bed  after  one  or 
two  of  these  evacuations.  It  is  not  long  before  vomiting  sets  in,  if 
the  attack  did  not  begin  as  a  cholerine.  In  an  hour  or  so  the  stom- 
ach becomes  uneasy  and  vomiting  begins — first,  the  contents  of  the 
stomach  and  some  bilious  matter,  and  then  the  peculiar  rice-water  dis- 
charges—  an  alkaline  fluid  containing  flocculi,  which  subsiding  are 
found  to  be  composed  of  epithelium,  ammoniaco-magnesian  phosphate, 
blood-corpuscles,  bacteria,  and  various  minute  organisms.  Sometimes 
the  quantity  of  blood-corpuscles  present  is  sufficient  to  give  the  whey- 
like fluid,  vomited  and  purged,  a  distinctly  reddish  hue.  In  every 
epidemic  there  are  cases  sinking  rapidly  without  vomiting  or  purging, 
all  the  other  phenomena  being  present.  These  are  called  cholera  sicca, 
but  incorrectly  so,  since  in  the  intestines  after  death  are  found  in 
great  quantity  the  characteristic  discharges.  The  vomiting  is  generally 
less  frequent  than  the  purging,  and  the  quantity  thrown  up  less.  The 
vomit  is  thrown  up  with  force  and  ejected  a  great  distance.  There  is 
intense  thirst,  and  great  draughts  of  water  are  swallowed,  to  be  quick- 
ly returned.  The  tongue  is  white,  pasty,  and  cold.  The  countenance 
shrinks,  has  a  leaden  hue,  and  the  eyes  are  staring,  the  nose  pinched, 
and  the  breath  cool.  A  good  deal  of  prsecordial  anxiety  is  felt  and 
breathing  is  oppressed,  even  difficult,  the  respiration  sighing,  or  a 
troublesome  hiccough  comes  on.  Very  soon  cramps  are  felt  in  the 
calves  of  the  legs,  and  although  they  occur  in  the  arms,  hands,  masse- 
ters,  muscles  of  the  back  and  abdomen  in  many  cases,  they  are 
more  severe  in  the  calves  than  elsewhere.  The  temperature  rapidly 
falls.  At  first  the  pulse  is  a  little  accelerated,  but  it  soon  declines 
in  volume  and  force,  becoming  extremely  small,  barely  perceptible,  or 
ceases  at  the  wrist,  while  the  action  of  the  heart  can  hardly  be  recog- 
nized. The  surface  gets  cold  and  is  covered  with  a  sticky  perspira- 
tion ;  the  skin  loses  its  elasticity  and  wrinkles,  so  that  the  hands  have 
the  sodden  look  known  as  the  "  washerwoman's  hands  "  ;  the  fingers, 
the  face,  and  the  nose  and  lips  especially,  are  blue  as  well  as  cold  ; 
the  eyes  are  sunken  and  are  surrounded  by  livid,  almost  black  rings  ; 
the  tongue  is  now  like  ice  and  the  breath  is  cold  ;  the  voice  is  weak, 
husky,  and  sepulchral,  and  the  urine  is  suppressed  entirely,  or  dimin- 


732  MIASMATIC   DISEASES. 

ished  to  a  few  drops,  wliich  is  often  found  to  be  albuminous.  The 
temperature  of  the  body  descends  to  the  level  of  the  surrounding 
media — to  96°,  92°,  even  80°  sometimes.  The  minimum,  according  to 
the  author's  observation,  was  92°  Fahr.  Such  is  the  algid  stage  of 
cholera,  or  cholera  asphyxia.  It  is  a  remarkable  circumstance  that 
patients  reduced  to  this  low  point,  collapsed  and  barely  living,  the 
blood  thick  and  hardly  in  motion,  should  yet  preserve  their  faculties, 
and,  when  roused,  return  correct  replies  to  the  queries  addressed  them. 
The  termination  of  this  state  is  usually  in  death,  but  reaction  may  be 
'  established,  introducing  the  third  stage. 

Death  rarely  occurs  in  less  than  twelve  hours  from  the  beginning 
of  symj)toms.  The  state  of  collapse  may  last  from  twelve  to  forty- 
eight  hours  and  even  then  recovery  ensue,  but,  of  course,  recovery  is 
exceptional  under  such  circumstances.  Again,  death  may  occur  in 
three  or  four  hours.  When  reaction  takes  place,  the  pulse  returns  at 
the  wrist  slowly,  and  at  first  doubtfully,  the  surface  very  gradually 
becomes  warmer,  the  countenance  assumes  a  more  natural  appearance 
and  the  cheeks  acquire  a  faint  flush,  the  tongue  is  less  cold,  there  is 
less  thirst,  the  respirations  are  deeper  and  easy,  and  the  temperature 
rises.  The  vomiting  and  purging  lessen  materially,  or  cease  altogether, 
but,  as  vomiting  and  purging  cease  in  the  final  collapse,  this  latter  con- 
dition should  not  be  mistaken  for  the  former.  The  secretion  of  urine 
and  the  substitution  of  normal  fasces  for  the  rice-water  discharges, 
above  all  other  symptoms,  announce  the  beginning  of  convalescence. 
If  albumen  be  present,  as  is  usual,  it  gradually  diminishes  and  disap- 
pears in  three  or  four  days.  The  return  to  health  may  occupy  a  few 
days  only,  but  more  frequently  a  week  or  more  will  be  required.  The 
reaction  may  not  be  complete.  The  stomach  continues  irritable,  thirst 
is  incessant,  and  indulgence  in  drinking  speedily  excites  vomiting.  The 
tongue  continues  coated,  or  peels  off,  leaving  a  dry  and  glazed  surface. 
The  epigastrium  remains  tender,  and  the  blandest  food  excites  pain 
and  is  apt  to  be  rejected.  The  bowels  do  not  act  well.  The  stools  are 
rather  grayish  and  mixed  with  bilious-looking  matters  without  having 
the  appearance  and  odor  of  faeces.  The  urinary  secretion  increases  in 
amount,  but  there  is  considerable  albumen  present.  There  is  also 
much  headache,  and,  while  a  condition  of  somnolence  is  tolerably  con- 
stant, there  is  little  genuine  sleep,  and  the  mind  is  clouded  with  illu- 
sions and  hallucinations.  This  imperfect  reaction  may  terminate  in 
recovery,  which  is  by  no  means  frequent,  or  some  acute,  intercurrent 
disease  may  arise,  or  the  patient  may  lapse  into  cholera  typhoid.  The 
reaction  may  pass  beyond  normal,  and  convalescence  be  delayed  by 
fever,  by  continued  irritability  of  the  stomach,  and  irregularity  of  the 
bowels.  The  eyes  are  watery,  the  cheeks  flushed,  and  the  face  is  spot- 
ted ;  more  or  less  headache,  tinnitus  aurium,  and  wakefulness  is  ex- 
perienced.    After  some  hours,  or  a  day  or  two,  these  symptoms  may 


CHOLERA.  733 

subside  and  convalescence  be  established,  or  they  may  pass  on  into  the 
cholera  typhoid.  Under  this  designation  of  cholera  typhoid  is  meant 
a  typhoid  state  compounded  of  reactionary  fever  and  uraemia.  When 
health  is  restored,  the  albumen  disappears  in  three  or  four  days,  but  in 
protracted  convalescence  the  albumen  persists,  varying  in  amount  from 
traces  to  ten  per  cent.  When  the  state  of  cholera  typhoid  is  developed, 
a  condition  of  great  debility  ensues  ;  there  are  severe  headache,  deeply 
injected  conjunctivae,  vertigo,  and  stupor.  They  lie  in  a  condition  of 
somnolence,  muttering  unintelligibly.  The  tongue  is  coated,  sordes 
accumulate  about  the  teeth  ;  there  are  thirst,  nausea,  sometimes  vomit- 
ing ;  the  abdomen  is  distended,  and  gurgling  can  be  induced  by  pressure 
over  the  ileo-caecal  valve  ;  there  is  diarrhoea,  the  stools  being  greenish 
and  liquid,  or  constipated,  or  these  states  may  alternate.  Eruptions, 
sometimes  like  roseola  or  like  urticaria,  or  erythematous,  appear  on 
the  hands,  and  spread  thence  over  the  body.  Cramps  are  apt  to  occur, 
and  there  may  be  convulsions  in  children.  In  the  fatal  cases,  stupor 
deepens  into  coma,  the  pulse  fails,  the  discharges  are  involuntary,  and 
death  occurs  in  collapse.  On  the  other  hand,  should  recovery  take 
place,  the  stupor  and  hebetude  of  mind  clear  up,  the  albumen  disap- 
pears from  the  urine,  the  vomiting  ceases,  some  appetite  returns,  and 
digestion  is  slowly  resumed.  So  damaged  have  been  the  organs  of 
digestion,  and  lowered  the  composition  of  the  blood,  that  convales- 
cence is  tedious,  some  weeks  being  consumed  in  the  work  of  restora- 
tion. Convalescence  is  often  complicated  by  bed-sores,  boils,  or  car- 
buncles, by  diphtheritic  exudation  of  the  fauces  or  larynx,  by  bron- 
chitis, pneumonia,  parotiditis,  etc. 

Course,  Duration,  and  Termination.— The  course  of  cholera  is  quite 
varied :  it  includes  a  period  of  incubation,  a  prodromic  stage,  the  first 
stage,  or  invasion  ;  the  second  stage,  or  algid  stage  ;  the  third  stage, 
or  reaction  ;  and  the  fourth  stage,  or  convalescence.  The  period  of 
incubation  is  irregular,  and  varies  from  one  day  to  a  week.  The  pro- 
dromic period  lasts  from  a  few  hours  to  a  day  or  two.  The  average 
duration  of  fatal  cases  is  about  sixty  hours,  and  of  cases  that  recover, 
about  nine  days.  Death  does  not  often  occur  within  the  first  twelve 
hours,  but  in  the  algid  condition.  The  usual  duration  of  the  typhoid 
stage  is  from  two  to  nine  days,  but  the  stage  of  reaction,  which  pre- 
cedes the  typhoid,  may  inaugurate  speedy  convalescence,  and  terminate 
by  the  fifth  or  sixth  day.  The  mortality  from  cholera  in  all  countries 
is  singularly  uniform,  the  average  of  various  epidemics  being  about 
fifty  per  cent.  In  some  epidemics  the  mortality  is  as  high  as  eighty 
per  cent.  ;  in  others,  as  low  as  twenty  or  thirty  per  cent.  The  last 
epidemic  in  this  country  was  much  less  formidable,  and  the  disease 
seemed  milder  than  former  ones.  In  fact,  each  visitation  since  the 
first  in  1832  has  manifested  less  virulence  than  the  preceding  one. 
The  cholera-germ  seems  to  be  naturalized  to  the  Mississippi  Valley, 


734  MIASMATIC   DISEASES. 

for  every  year  since  the  last  great  epidemic  numerous  cases  occurred  in 
all  respects  like  those  during  the  spread  of  epidemics.  The  mortality 
is  generally  greater  at  the  beginning  of  an  epidemic  than  at  its  close. 
Of  the  large  number  brought  under  the  cholera  influence  during  an 
epidemic  prevalence  of  the  disease,  but  few  comparatively  are  attacked. 
In  many  the  germs  received  into  the  intestines  excite  no  disturbance  ; 
in  others,  there  is  produced  merely  a  cholera-diarrhoea  ;  in  still  others, 
a  fully  developed  cholera-seizure  follows.  The  prognosis  is  influenced 
by  age,  habits  of  life,  and  hygienic  surroundings.  Infancy,  old  age, 
a  debilitated  constitution,  evil  habits,  especially  alcoholic  excess,  and 
living  amid  the  most  active  sources  of  infection,  greatly  increase  the 
danger  of  an  attack.  In  an  attack  of  cholera  the  prognosis  must  rest 
on  the  condition  of  the  individual  at  the  time  of  the  seizure,  and  on  the 
severity  of  the  attack,  the  prompt  development  of  the  algid  state  being 
especially  of  evil  import.  The  signs  of  evil  import  during  the  stage 
of  reaction  are  imperfect  reaction,  confusion  of  mind,  suppression  of 
urine,  and  involuntary  discharges.  If  reaction  is  well  established,  and 
instead  of  convalescence  cholera  typhoid  comes  on,  the  condition  must 
be  regarded  as  unfavorable,  although  recovery  is  not  impossible. 

Treatment. — It  is  important  to  recognize  diarrhoea  and  cholerine 
as  portions  of  the  morbid  complexus.  No  case  of  diarrhoea  is  unde- 
serving of  attention  during  the  existence  of  a  cholera  influence.  The 
great  remedy  is  opium  ;  its  imjDortance  is  testified  to  by  the  fact  that 
this  agent,  in  some  form,  enters  into  all  the  cholera  remedies,  secret 
and  published.  As  the  cholera-discharges  are  distinctly  alkaline,  and 
as  inward  osmosis  can  only  be  propeiiy  set  up  by  the  administration 
of  an  acid,  this  physical  fact  should  be  recognized  in  the  prescrip- 
tions. Experience  is  in  accord  mth  theory  in  respect  to  the  value  of 
an  acid.  The  following  combinations  for  the  cholera-diarrhoea  the 
author  has  found  very  effective  :  ]^.  Acid,  suljjhuric.  aromat.,  tinct. 
opii  deodorat.,  aa  §  j.  M.  Sig.  Ten  to  thirty  drops  in  water  every 
hour  or  two.  I^ .  Acid,  sulphuric,  dilut.  3  ss.,  tinct.  opii  camphorat. 
f  jss.  M.  Sig.  A  teaspoonful,  well  diluted,  every  half -hour  to  every 
two  hours.  Paregoric,  fortified  by  tincture  of  opium,  is  an  efiicient 
remedy.  Many  prefer  acetate  of  lead  and  opium  in  pill-form,  or  in 
solution.  A  favorite  combination  is  spirits  of  chloroform,  tincture 
of  rhubarb,  tincture  of  cinnamon,  and  tincture  of  opium.  One  of 
the  most  successful  remedies  for  the  preliminary  diarrhoea  is  the 
proprietary  medicine  chlorodyne,  which  has  been  largely  used  in  the 
East  Indies.  According  to  Brown-Sequard,  who  bases  his  practice  on 
experience  acquired  in  the  West  India  Islands,  cholera  can  certainly 
be  prevented  by  giving  sufficient  morphia  in  time.  If  the  attack  be- 
gin by  cholerine,  there  is  no  remedy  so  efficacious  as  the  hypodermatic 
injection  of  morphia  and  atropia  (^  grain  of  morphia  and  yio"  grain  of 
atropia).     Indeed,  it  may  be  affirmed  that  the  subcutaneous  injection 


CHOLERA.  735 

of  morphia  is  the  most  efficient  treatment  of  both  forms  of  prelimi- 
nary disturbance  and  of  the  first  stage  of  the  attack  proper.  Besides 
the  medicinal  remedies  for  this  stage  of  the  disease,  the  utmost  quiet 
must  be  enjoined.  The  food  taken  should  consist  of  boiled  milk,  a 
soft-boiled  egg,  some  beef  or  mutton  broth,  or  a  moderate  quantity  of 
steak  or  roasted  beef.  If  the  symptoms  be  threatening,  the  aliment 
should  not  include  any  solids.  As  thirst  is  excessive,  the  patient  should 
be  allowed  ice  ad  libitum,  which  he  should  be  encouraged  to  swallow  fre- 
quently in  small  quantities.  Effervescent  drinks  are  extremely  grate- 
ful, and  very  useful  when  the  vomiting  begins.  Fermented  drinks, 
as  beer  and  champagne,  are  objectionable,  but  carbonic-acid  water  and 
effervescing  powders  are,  on  the  other  hand,  very  serviceable.  Rec- 
ognizing the  fact  of  the  alkalinity  of  the  discharges,  we  should  give 
an  acid  reaction  to  the  effervescing  powder  by  increasing  the  relative 
proportion  of  acid.  Mustard  to  the  epigastrium,  or  a  flying-blister, 
will  aid  in  the  arrest  of  vomiting.  The  subcutaneous  injection  of  mor- 
phia is  still  more  efficient.  The  author  must  here  strongly  insist  on 
the  futility  and  danger  of  deep  vesication  so  often  practiced  in  cholera, 
for  he  has  seen  an  inflammation  of  all  the  tissues  of  the  abdominal 
wall,  extending  to  the  peritoneum,  produced  by  blisters  to  the  abdo- 
men in  the  algid  stage.  Other  remedies  for  the  vomiting  are  carbolic 
acid,  w^hich  often  acts  very  admirably,  chlorodyne,  hydrocyanic  acid, 
tincture  of  camphor,  chloroform,  nitrite  of  amyl,  chloral,  etc.  Of  all 
the  remedies  for  this  stage,  the  author  has  had  the  best  results  from 
the  hypodermatic  injection  of  chloral — of  which  a  scruple  may  be  in- 
jected every  hour  or  two,  dissolved  in  a  sufficient  quantity  of  water. 
It  allays  the  cramps,  and  brings  about  reaction.  It  seems  to  act  most 
efficiently  when  administered  with  moi'phia,  or  in  alternation  with  the 
latter  remedy.  Good  effects  have  followed  the  injection  of  atropia  in 
the  algid  stage,  to  excite  the  heart  to  action,  and  to  restore  warmth  to 
the  surface,  Amyl  nitrite  has  been  used  by  inhalation  to  obtain  the 
same  effect,  and  apparently  with  advantage.  When  the  heart  is  failing 
and  the  surface  becoming  cold,  there  is  a  strong  temptation  to  the  free 
use  of  stimulants,  and  the  stomach  is  kept  full  of  brandy,  camphor, 
ether,  ammonia,  and  other  stimulants.  As  these  articles  can  not  be 
absorbed,  they  serve  to  keep  up  vomiting.  As  the  circulation  declines, 
a  little  brandy  will  be  useful,  but  any  considerable  quantity  should 
not  be  given.  Whisky  can  be  thrown  under  the  skin.  The  intrave- 
nous injection  of  milk  has  proved  successful  in  the  hands  of  Hodder, 
in  the  collapse  of  cholera,  and  the  intravenous  administration  of  salines 
has,  in  apparently  desperate  cases,  brought  on  reaction,  but  which,  un- 
fortunately, is  not  always  maintained.  In  this  direction  must  be  looked 
for  the  most  successful  management  of  the  algid  stage  of  cholera  in 
future  epidemics.  During  reaction  the  stomach  must  be  handled  very 
cautiously,  lest  vomiting  be  excited.     The  digestive  powers  are  so  fee- 


Y36  MIASMATIC   DISEASES. 

ble  that  it  is  useless  to  give  any  food  except  a  little  hot  milk  or  a  little 
weak  broth.  The  vomiting  and  diarrhoea  which  are  so  troublesome 
at  this  time  are  probably  best  relieved  by  carbolic  acid  and  bismuth 
(3-  Acid,  carbolic,  gr.  viij,  bismuthi  subnitrat.  3  ij,  mucil.  acacise, 
aquse  lauro-cerasi,  aa  |  j,  M.  Sig.  A  teaspoonful  every  hour  or  two). 
If  there  are  fever  and  headache,  bromide  of  potassa  will  give  relief. 
As  the  cholera  typhoid  is  a  condition  of  uraBmia,  efforts  should  be  di- 
rected to  restore  the  urinary  secretion,  and  the  treatment  ought  to  be 
conducted  according  to  the  principles  already  laid  down.  As  it  is 
probable  that  the  poison  of  cholera  is  contained  in  the  discharges, 
these  should  be  disinfected  at  once  by  a  strong  solution  of  the  chlo- 
ride of  zinc.  The  linen  about  a  patient,  experience  has  shown,  is  pecu- 
liarly dangerous.  When  the  loss  is  not  important,  disinfection  by 
burning  should  be  practiced  ;  otherwise  the  material  should  be  thrown 
into  boiling  water,  and  should  not  be  handled  until  thoroughly  boiled. 
Articles  of  clothing  should  be  hung  up  in  an  atmosphere  of  sulphurous 
acid  for  a  number  of  days.  During  the  existence  of  an  epidemic,  the 
hours  should  be  regular  and  all  excesses  avoided.  The  mistake  made 
by  changing  from  a  full  to  a  very  restricted  diet  has  cost  many  lives. 
The  ordinary  fruits  and  vegetables  of  the  season  should  be  taken  in 
moderation.  Everything  indigestible  should  be  avoided.  Calmness 
favors  health,  while  fear  invites  disease.  Attention  to  the  first  indica- 
tions of  disease  may  save  an  attack.  Questions  of  public  hygiene  are 
not  embraced  within  the  scope  of  this  work. 


DIPHTHERIA. 

Definition. — Dijyhtheria  is  an  acute,  specific,  contagious  disease,  be- 
ginning by  an  infection  of  the  throat,  and  characterized  by  a  local  exu- 
dation, and  glandular  enlargements,  systemic  poisoning,  and  having 
for  its  sequelae  various  paralyses. 

Causes. — As  diphtheria  is  a  communicable  and  an  inoculable  dis- 
ease, it  is  propagated  by  a  specific  poison,  the  form  of  which  is  not 
known,  although  suspected  to  exist  as  a  minute  organism.  The  simul- 
taneous discovery  by  Hueter  and  Oertel  of  a  minute  organism  of  the 
bacteria  group,  in  the  exudation,  the  mucous  membrane,  neighboring 
vessels  and  lymphatics,  and  in  the  blood,  at  once  attracted  attention  to 
this  parasite  as  the  infecting  principle.  Virchow's  discovery  of  the 
presence  of  micrococci  colonies  in  ulcerative  endocarditis  and  elsewhere 
furnishes  strong  support  to  this  theory  of  diphtheria.  On  the  other 
hand,  the  filtration  experiments  of  Burdon-Sanderson  have  cast  serious 
doubts  on  the  immediate  agency  of  micrococci ;  they  seem  rather  to 
enact  a  secondary  role,  but,  according  to  either  position,  they  are  neces- 
sary to  the  diphtheritic  process.  Diphtheria  prevails  as  an  epidemic  ; 
under  some  circumstances  it  is  endemic,  and  it  also  occurs  sporadically. 


DIPHTHERIA.  ^^7 

Diphtheria  is  closely  allied  to  scarlet  fever,  and  it  occurs  during  the 
course  of  measles,  small-pox,  typhus,  puerperal  fever,  exudations  de- 
veloping in  the  fauces  during  the  progress  of  these  diseases,  and  on  the 
genitalia  in  the  last  mentioned.*  Indeed,  it  seems  well  established 
that  the  materies  morbi  of  these  low  forms  of  fever  favor  the  develop- 
ment of  the  diphtheria-poison.  While  the  disease  occurs  more  or  less 
throughout  the  whole  range  of  civilization,  it  is  more  prevalent  in  the 
temperate  regions.  It  is  more  apt  to  prevail  as  an  epidemic  during 
the  winter  and  spring,  but  epidemics  have  occurred  at  all  seasons. 
Like  all  other  diseases  of  the  same  kind,  all  the  conditions  of  bad  hy- 
giene increase  its  virulence  and  favor  its  diffusion.  Unquestionably, 
the  chief  cause  of  its  spread  is  contagion.  Many  nurses  and  physicians 
have  fallen  victims  to  their  devotion.  "  When  it  breaks  out  in  a  fam- 
ily, all  the  children  are  commonly  affected  with  it,  if  the  healthy  are 
not  kept  apart  from  the  sick  ;  and  such  adults  as  are  frequently  with 
them,  and  receive  their  breath  near  at  hand,  seldom  escape  some  degree 
of  the  same  disease."  f  The  experience  of  the  last  century  is  the  same 
to-day.  As  a  rule,  the  more  severe  the  case  of  diphtheria,  the  more 
intense  the  activity  of  the  poison.  When  there  are  several  bad  cases 
in  a  small  apartment  not  ventilated,  the  poison  becomes  denser  and 
more  virulent,  and  conversely,  when  there  is  a  single  case  in  a  large, 
well- ventilated  apartment,  the  poison  is  diluted,  and  its  virulence  less- 
ened. The  young,  above  one  year,  are  more  susceptible  than  adults, 
the  greatest  mortality  being  attained  from  the  second  to  the  fifth  year. 
Boys  seem  more  apt  to  get  the  disease  than  girls,  a  fact  which  Fother- 
gill  noted  in  the  epidemics  of  the  middle  of  the  last  century.  An  acute 
catarrh  of  the  fauces  seems  to  invite  the  contagion,  and  although  one 
attack  does  not  confer  an  immunity  against  subsequent  attacks,  a  con- 
siderable interval  occurs  between  them.  When  we  hear  of  children 
having  diphtheria  every  year,  we  have  a  right  to  assume  that  errors  of 
diagnosis  have  been  committed.  The  poison  of  diphtheria  exists  in 
the  exudations  and  secretions  of  the  fauces,  and  it  is  chiefly  by  means 
of  this  that  the  disease  is  communicated.  Those  engaged  in  swabbing 
the  throat  receive  this  matter  as  it  is  ejected  in  coughing,  or  with  the 
exhaled  breath.  Several  physicians  have  been  poisoned  by  blowing 
through  a  trachea  canula.  Articles  of  clothing  may  contain  particles 
of  matter  for  a  long  time  adherent  to  them.  Doubtless  the  poison 
floats  in  the  atmosphere  at  a  considerable  distance  from  the  original 
source.  It  adheres  with  considerable  tenacity  to  the  walls,  floors,  bed- 
stead, and  articles  of  furniture,  but  especially  to  bedding,  carpets,  cur- 
tains, and  woolen  goods  of  all  kinds.  Not  all  who  come  in  contact 
with  the  germ  or  poison  have  diphtheria,  for  individual  susceptibility 

*  Virchow's  "Arcbiv,"  Bd.  ix,  s.  228,  1856. 

f  "  An  Account  of  the  Putrid  Sore  Throat,"  by  John  Fothergill,  II.  D.,  fifth  edition, 
London,  1769,  p.  31. 

47 


738  MIASMATIC   DISEASES. 

and  predisposition  are  important  factors.  When  the  predisposition 
exists,  and  exposure  is  effected,  a  certain  interval  elapses  before  there 
are  any  objective  signs  of  the  disease.  This  period  of  incubation  is 
very  variable,  and  the  variations  are  due  to  the  differences  in  the  in- 
tensity of  the  poison  and  the  systemic  state  of  those  poisoned.  The 
more  malignant  the  disease  and  the  more  depraved  the  bodily  condi- 
tion, the  more  quickly  mil  the  symptoms  of  the  disease  apjDear  after 
reception  of  the  disease-germs.  If  the  poison  come  in  contact  with  an 
abraded  surface,  it  secures  immediate  admission  to  the  blood,  and  then 
the  stage  of  incubation  may  not  exceed  two  days.  Admitted  to  the  sys- 
tem in  the  ordinary  way,  the  period  of  incubation  will  vary  from  thi-ee 
to  ten  days.  By  Oertel  it  is  placed  at  two  to  five  days.  According  to 
the  author's  observations,  the  jDeriod  of  incubation  during  the  epidemic 
prevalence  of  the  disease  is  in  the  largest  number  of  cases  three  days. 

Pathological  Anatomy. — Except  for  the  nicer  pathological  distinc- 
tions of  modern  methods,  we  might  adopt  the  description  of  Fother- 
gill  *  as  an  account  suitable  for  to-day  of  the  lesions  of  diphtheria. 
The  first  change  consists  in  hypersemia — a  vivid  injection  of  the  mu- 
cous membrane  of  the  fauces.  At  the  end  of  twenty-four  hours  a 
faint,  grayish-white  pellicle  appears  on  the  surface  of  the  soft  palate, 
the  pillars  of  the  fauces,  the  pendulum,  or  the  tonsils.  The  patches 
may  be  no  larger  than  pin-heads,  and  scarcely  thick  enough  to  jirevent 
the  membrane  showing  through  them.  In  a  few  hours  they  greatly 
increase  in  number,  coalesce  over  spaces  having  the  area  of  three  or 
four  lines,  and  thicken,  so  that  they  appear  like  bits  of  curds  on  the 
surface  of  the  membrane.  Now  there  appear,  constituting  the  exudation 
and  piercing  the  mucous  membrane,  forcing  apart  the  epithelial  cells, 
great  numbers  of  round  bodies,  highly  refracting  single  cells  with  thick 
walls — the  micrococci.  Masses  of  them,  united  in  bundles  and  colo- 
nies, form  distinct  nodules,  projecting  above  and  making  their  way 
into  the  deepest  part  of  the  mucous  membrane. f  Leucocytes — pus- 
corpuscles — soon  appear,  but  not  in  great  numbers,  in  the  deep  layers 
of  the  mucous  membrane,  and  they  are  coated  by  micrococci,  and  these 
bodies  have  also  penetrated  their  interior  ;  but,  as  the  process  extends, 
pus-cells  increase  in  number  and  spread  out  through  the  basement 
membrane  and  through  the  epithelial  cells  surrounding  the  micrococci 
colonies  on  all  sides.  Among  the  pus-corpuscles  now  apj^ear  young 
cells  three  or  four  times  larger  than  the  former,  and  they  multiply  in 
large  numbers — their  nuclei  surrounded  by  a  thin  layer  of  protoplasm, 
accumulating  also.  Thus  is  formed  a  mass  composed  of  micrococci, 
pus-cells,  and  newly  formed  cellular  elements,  which  constitute  a  mem- 

*  Fothergill  did  not,  as  Bretonneau  points  out,  properly  distinguish  the  diphtheritic 
Bore-throat  of  scarlet  fever  from  diphtheria. 

+  Dr.  L.  Letzerich,  "  Beitrage  zur  Kenntniss  dcr  Diphtheritis,"  Virchow's  "  Archiv," 
Band  slvi  und  xlvii,  1869. 


DIPHTHERIA.  739 

branous  patch  that  may  be  lifted  off  the  surface.*  In  the  croupous 
form  a  quantity  of  fibrin  is  exuded  when  the  local  process  has  reached 
the  development  above  described.  This  fibrin  is  poured  out  into  the 
epithelium,  and  between  the  epithelium  and  the  basement  membrane  or 
"  sub-epithelial  tissue."  The  epithelial  cells  rapidly  undergo  necrosis  ; 
a  network  of  fibrin  develops  between  them,  and  colonies  of  micrococci 
form  in  the  outer  layer  of  the  false  membrane.  Succeeding  exudations 
lift  up  the  first-formed  false  membrane,  and  between  them  capillary 
hiemorrhages  may  take  place,  and  thus  the  extra vasated  blood  is  inclosed 
in  the  meshes  of  the  fibrinous  exudation.  Meanwhile  the  micrococci 
penetrate  deeper,  new  deposits  of  fibrin  occur,  and  hence  the  false  mem- 
brane increases  in  all  directions  and  new  ones  are  formed.  The  mem- 
brane is  detached  and  cast  off  by  a  cessation  of  the  fibrin  exudation  and. 
an  abundant  formation  of  pus  elements.  The  micrococci  penetrate  to 
the  lymphatics  and  lymph-canals,  unless  cut  off  from  penetrating  below 
by  the  abundance  of  the  fibrinous  exudation.  The  mucous  membrane 
of  the  nose,  larynx,  and  air-passages,  undergoes  similar  changes  in  the 
process  of  formation  of  a  false  membrane.  When  recovery  takes  place 
the  fibrin  exudations  cease,  and  the  false  membrane  is  broken  up  and 
detached  by  the  abundant  formation  of  merely  purulent  cells.  The 
epithelium  destroyed  is  restored  by  the  formation  of  new  cells  pro- 
duced from  the  sub-epithelial  layer.  In  the  septic  form  the  masses  of 
false  membrane  undergo  decomposition,  bacteria  form  in  immense 
numbers,  and  the  micrococci  penetrate  to  the  deepest  part  of  the  mu- 
cosa, filling  in  the  sub-epithelial  and  sub-mucous  tissues.  It  is  gener- 
ally conceded  that  the  diphtheritic  process  as  it  occurs  in  the  nose  is 
more  apt  to  produce  septic  infection.  Here  the  micrococci  accumulate 
in  the  greatest  numbers,  and  seem  possessed  of  the  greatest  activity  ; 
for  the  periosteum,  the  cartilages,  even  the  bones,  are  attacked.  Gan- 
grene is  produced  in  consequence  of  the  rapid  increase  in  cells,  the 
exudations  of  fibrin,  and  the  crowding  of  the  tissues  by  micrococci, 
arresting  the  blood-supply  and  stopping  the  nutritive  processes,  hence 
causing  a  necrobiosis,  which  is  extensive  in  proportion  to  the  spread 
of  the  membrane  formation.  When  this  occurs,  *'  false  membrane 
mucosa,  and  submucosa  form  together  one  semi-liquid,  discolored, 
dark  pulp,  or  a  darkish,  wormwood-like,  broken-down  mass,  or  a  dark, 
more  firmly  attached  slough,  from  which  the  intense,  peculiar  odor  of 
gangrene  is  spread."  f 

*  Burdon-Sanderson  long  ago  described,  with  his  usual  fidelity,  the  fibrin,  the  cellular 
elements,  and  the  transparent  granules  (micrococci  ?)  which  unite  to  make  up  the  false 
membrane.  ("  Contributions  to  the  Pathology  of  Diphtheritic  Sore  Throat,"  etc.,  "  Brit- 
ish and  Foreign  Medico-Chirurgical  Review,"  January,  1860,  p.  179,  et  seq.) 

•)•  Oertel,  Ziemssen's  "  Cyclopaedia,"  vol.  i,  whom  we  have  chiefly  followed  in  this 
account  of  the  pathological  conditions  ;  also  Jafife,  Schmidt's  "  Jahrbiicher,"  fiinfter 
Artikel,  vol.  clviii,  p.  73. 


740  MIASMATIC  DISEASES. 

The  lymphatics  of  the  neck,  whose  vessels  take  their  origin  in  the 
tissues  included  in  the  diphtheritic  process,  are  also  involved.  The 
micrococci  penetrate  to  the  vasa  efferentia,  and  are  seen  crowding 
these  vessels  in  large  numbers.  The  lymphatic  glands  of  the  part — 
submaxillary,  sublingual,  parotid — and  the  chain  of  cervical  lymphat- 
ics underlying  the  stemo-cleido-mastoid  are  enlarged  more  or  less  ex- 
tensively. The  periglandular  and  the  general  connective  tissue  are 
swollen,  infiltrated  with  pus  and  lymphoid  cells,  and  there  may  be  also 
around  the  glands  extravasations  of  blood.  The  swelling  of  the  glands 
themselves  is  due  to  a  hyperplasia  of  the  cells,  the  stroma  remaining 
unaffected.  The  membranous  exudations,  in  a  small  proportion  of 
cases,  extends  to  the  bronchi,  but  only  involving  a  part  of  the  tubes. 
The  changes  in  the  lungs  are  due  to  the  mechanical  obstruction  of 
bronchi,  the  consequences  being  atelectasis,  emphysema,  and  localized 
oedema.  When  the  diphtheritic  process  invades  the  lung-tissue  itself, 
there  will  be  seen  at  various  points  extravasations  of  blood,  and  infarc- 
tions, and  alveoli  distended  with  cellular  elements — epithelium,  blood- 
corpuscles,  and  new  cells,  etc. — and  micrococci  colonies.  In  cases  of 
septic  infection,  the  muscular  tissue  of  the  heart  becomes  soft,  is  easily 
torn,  and  its  fibrillse  are  far  advanced  in  fatty  degeneration,  while  at 
various  points  are  extravasations  of  blood  into  the  muscular  substance. 
Ulcerative  endocarditis,  due  to  the  development  of  bacterian  colonies, 
thickening  and  vegetations  of  the  valves,  with  the  secondary  conse- 
quences of  this  condition  of  the  endocardium,  have  been  repeatedly 
demonstrated.*  The  composition  of  the  blood  is  much  altered  in  the 
cases  of  severe  toxaemia  :  it  is  black,  fluid,  rather  mucilaginous,  and 
stains  the  fingers  a  brownish  color.  Important  changes  occur  in  the 
kidneys,  and  at  a  very  early  period  of  the  disease.  They  are  swollen, 
intensely  hypersemic  in  the  severe  cases,  but  little  so  in  the  mildest ; 
but,  in  all  cases,  changes  occur  in  the  Malpighian  tufts  and  in  the 
tubules.  The  tufts  are  hsemorrhagic,  contain  micrococci  colonies,  and 
are  surrounded  by  lymphoid  cells  ;  the  epithelium  of  the  tubules  is 
cloudy,  granular,  and  swollen,  and  is  often  detached  in  the  form  of 
casts  with  epithelium  adherent.  The  brain  is  hypersemic,  and  there 
are  numerous  capillary  hsemorrhages,  but  the  most  interesting  changes, 
which  serve  to  explain  the  secondary  paralyses,  are  those  occurring  in 
the  spinal  nerve-roots,  which  are  thickened,  while  in  the  sheaths  of  the 
nerves  hsemorrhagic  extravasations  occur,  and  they  are  also  filled  with 
lymphoid  cells  and  nuclei.  Important  changes  occur  in  the  muscles, 
beginning  at  any  point  of  infection.     Capillary  hsemorrhages  f  occur 

*  "  Ueber  diphtherische  Endocarditis,"  von  C.  J.  Eberth  in  Zurich,  Virchow's  "  Ar- 
chiv,"  Band  Ivii,  s.  228,  et  seq. 

f  Jhe  constant  appearance  of  capillary  haemorrhages,  in  various  parts,  referred  to  in  the 
text,  is  regarded  as  highly  characteristic.  Jaffe,  "  Die  Diphtheric,"  etc.,  Schmidt's  "  Jahr- 
biicher,"  Band  clvii,  s.  73.    An  elaborate  article,  extending  through  five  issues  of  the  journal. 


DIPHTHERIA.  Y41 

in  them,  and  the  strioB  disappear  in  the  course  of  a  fatty  and  granular 
degeneration.  Those  muscles  lying  immediately  under  the  affected 
mucous  membrane  are  apt  to  undergo  these  changes,  because  invaded 
directly  by  the  pathological  products  of  the  diphtheritic  process. 

Symptoms. — There  are  well-marked  forms  of  diphtheria — the  catar- 
rhal, the  croupous,  the  septicsemic,  and  the  gangrenous.  In  the  de- 
scription of  the  morbid  appearances  these  natural  divisions  were  kept 
in  view,  and  all  who  have  had  any  considerable  experience  with  the 
disease  will  recognize  the  adherence  to  nature  of  these  forms.  In  the 
catarrhal  form,  the  initial  symptoms  are  those  of  an  ordinary  catarrh. 
Heat,  irritation,  and  pain  are  felt  in  the  throat,  and,  on  the  attempt  to 
swallow,  much  soreness  is  experienced.  Chilliness  followed  by  some 
slight  fever,  headache,  backache,  and  general  muscular  pains  are  usu- 
ally present,  but  in  the  mildest  cases  only  some  slight  general  malaise 
may  result.  In  still  other  cases  the  symptoms  may  be  more  pro- 
nounced :  high  fever,  severe  sore  throat,  violent  headache,  tinnitus, 
considerable  debility,  nausea,  and  vomiting  may  be  experienced.  On 
examination  of  the  fauces,  there  are  seen  more  or  less  intense  hyper- 
jemia,  and  on  the  palate  or  tonsils  minute  grayish-white  patches,  very 
thin,  and  firmly  adherent.  The  tongue  is  covered  with  a  thick  white 
coating,  which  extends  well  forward  to  the  tip,  and  is  also  pertina- 
ciously adherent  to  the  organ.  In  a  day  or  two,  sometimes  more  rap- 
idly, the  patches  of  false  membrane  extend  over  the  tonsils,  the  pillars, 
and  the  pharynx  by  a  union  of  numerous  centers  of  deposit,  and  not 
by  a  marginal  growth  only.  The  thickness  of  this  membrane  is  at 
this  time  a  line  or  two,  and  it  is  distinctly  outlined  against  the  dark- 
red  mucous  membrane  about  it.  The  color  of  the  membrane  is  gray- 
ish-white, but  it  varies  from  that  shade  to  dark  red,  or  even  black. 
The  reddish  tint  is  due  to  extravasation  of  blood,  and  inclosure  of  the 
blood  in  the  meshes  of  the  exuded  fibrin.  In  the  catarrhal  form,  how- 
ever, but  few  cases  attain  to  such  an  extent  of  false  membrane  ;  there 
are  a  few  patches  which  may  coalesce  and  be  limited  to  one  side,  and 
they  reach  their  maximum  by  the  third  day,  when  already  the  mucous 
membrane  has  become  paler,  and  the  exudation  is  loosening  at  the 
margins.  The  fever  which  appeared  at  the  outset  has  by  this  time 
disappeared,  but  in  most  of  the  cases  of  the  catarrhal  form  there  is  no 
fever,  or  it  ceases  after  the  first  day.  The  general  disturbance  ceases 
with  the  fever,  except  the  debility,  which  seems  in  marked  contrast  to 
the  apparent  severity  of  the  disease.  Soreness  of  the  throat,  pain  in 
swallowing,  and  some  tumefaction  of  the  submaxillary  and  deep  cer- 
vical glands  continue  up  to  the  detachment  of  the  false  membrane, 
which  may  take  place  about  the  sixth  day.  When  the  false  mem- 
brane is  detached,  the  mucous  membrane  appears  red  and  still  swollen, 
but  its  continuity  is  restored  by  the  production  of  new  epithelium.  In 
the  more  severe  cases  the  detachment  of  the  false  membrane  is  not 


742  MIASMATIC   DISEASES. 

effected  until  some  days  later,  the  debility  is  considerable,  and  conva- 
lescence requires  several  days  longer.  The  mildest  cases  of  the  catar- 
rhal form  may  be  followed  by  diphtheritic  paralyses  and  other  sequelae. 
Croupous  Form. — This  form  may  begin  as  the  ordinary  catarrhal 
variety,  and  continues  to  the  formation  of  the  false  membrane,  with- 
out any  indications  of  a  departure  from  the  usual  course,  untU  the 
fourth  or  fifth  day,  when  it  takes  on  a  new  character  by  the  sudden 
development  of  a  high  fever,  increased  tumefaction  of  the  glands, 
spreading  of  the  false  membrane,  etc.  When  the  case  from  the  be- 
ginning assumes  the  severity  belonging  to  the  croupous  form,  it  sets 
in  with  violent  symptoms — with  chilliness  but  not  a  chill,  followed  by 
high  fever  ;  or  the  fever  begins  at  once  with  the  onset  of  other  symp- 
toms, the  temperature  rising  to  103°,  104°,  or  105°  Fahr.  The  usual 
symptoms  of  the  feverish  state  are  also  present — headache,  general 
pains,  thirst,  and  restlessness  at  night,  occasionally  delirium.  Then 
occur  the  special  symptoms  referable  to  the  throat — a  sense  of  heat 
and  burning,  and  severe  pain  in  the  act  of  swallowing.  The  sublingual 
and  submaxillary  glands  are  swollen,  and  especially  the  deep  cervical 
lymphatics  lying  under  the  sterno-cleido-mastoid,  which  are  not  en- 
larged in  other  affections  of  the  throat.  The  swollen  glands  are 
hard  and  tender,  and  the  infiltrated  connective  tissue  about  them  is 
also  sensitive  to  pressure.  The  mucous  membrane  is  intensely  hy- 
peraemic  in  parts,  especially  on  the  pendulum,  the  palate,  the  pillars  of 
the  fauces,  and  the  tonsils,  and  it  is  swollen  and  cedematous.  On  this 
dark-red  ground  appears,  in  a  few  hours,  the  false  membrane  in  small 
patches  of  grayish-white,  and,  in  the  course  of  the  next  twenty-four 
hours  it  has  developed  into  a  thick,  yellowish-gray  membrane,  which, 
becoming  drier  and  darker,  presents  an  appearance  not  unlike  the  rind 
of  bacon.  In  the  course  of  subsequent  changes  the  false  membrane 
assumes  a  yellowish-gray  shade,  someT\'hat  like  sole-leather.  The 
change  in  tints  is  at  first  due  to  the  inclosure  of  blood  within  the 
meshes  of  the  exuded  fibrin,  and  afterward  to  the  great  increase  of 
the  pus-corpuscles.  If  this  thick,  tenacious,  leather-like  false  mem- 
brane is  now  removed,  the  epithelium  comes  with  it,  leaving  a  raw, 
dark-red,  bleeding  surface  beneath.  Another  false  membrane  may  form 
on  this  surface,  or  it  may  undergo  healing  in  the  mode  already  de- 
scribed. While  the  development  of  the  local  morbid  process  is  pro- 
ceeding, the  general  condition  may  improve,  the  fever  declining  to 
near  normal,  the  appetite  returning,  and  strength  increasing.  An  ar- 
rest of  the  local  process  may  be  effected  at  the  end  of  the  first  or  be- 
o-inning  of  the  second  week,  the  membrane  become  detached,  and 
convalescence  be  slowly  established.  More  frequently,  however,  while 
this  apparent  improvement  is  taking  place,  the  false  membrane  is 
spreading  in  all  directions.  Usually,  when  no  attempt  at  the  arrest  of 
the  disease  is  made,  the  fever  rises  higher,  the  difficulty  in  swallowing 


DIPHTHERIA.  Y43 

increases,  and  the  patient  is  tormented  by  efforts  to  rid  the  throat  of  a 
tough  secretion.  At  this  period  of  the  disease,  a  condition  of  profound 
adynamia  may  come  on,  and  death  ensue  in  collapse.  Otherwise,  the 
disease  pursues  its  course,  the  false  membrane  extends,  the  swelling  of 
the  neck  increases  to  formidable  proportions,  the  salivary  glands  pour 
out  a  quantity  of  offensive  saliva,  and  from  the  fauces  is  exhaled  a 
horrible  fetor  which  awakens  suspicions  of  the  setting  in  of  gangrene. 
If  the  exudation  does  not  extend  to  the  larynx,  the  breathing,  though 
heavy,  is  not  dyspnoeic,  and  the  voice,  though  muffled  and  nasal,  is 
not  toneless.  The  appetite  is  utterly  gone,  the  stomach  rather  unset- 
tled, although  vomiting  is  not  iisual,  and  the  bowels  are  rather  consti- 
pated, but  vomiting  and  diarrhoea  may  both  exist,  caused,  it  may  be, 
by  the  swallowing  of  the  ichorous  matters  produced  in  the  throat. 
The  urine  is  scanty  and  high-colored,  and  in  the  great  majority  of 
cases  contains  albumen  (Squire  *),  and  the  quantity  of  urea  is  increased 
— at  the  maximum  of  the  disease,  doubled.  Casts  of  the  tubules  with 
ejDithelium,  adherent  and  hyaline  cases,  have  also  been  observed  in  the 
cases  of  albuminuria.  When  the  disease  has  reached  the  point  in  its 
development  just  described,  slow  recovery  may  take  place,  as  already 
mentioned,  or  the  disease  may  extend  into  the  nares,  downward  into 
the  larynx  and  trachea,  or  into  the  Eustachian  tube.  As  there  are 
some  special  features  introduced  into  the  symptomatology  by  such 
extension  of  the  morbid  process,  it  becomes  necessary  to  enter  into 
brief  details  on  these  points.  When  the  membrane  spreads  into  the 
nose,  a  disagreeable  sense  of  stuffing  is  produced,  the  patient  breathes 
through  the  mouth,  epistaxis  frequently  occurs,  and  an  ichorous  muco- 
purulent discharge  flows  from  the  anterior  nares,  excoriates  the  upper 
lip,  and  on  this  raw  surface  not  unfrequently  a  false  membrane  forms. 
This  is  a  serious  complication,  owing  to  the  fact  that  septicaemia  is 
very  apt  to  be  produced,  and  death  may  be  caused  by  profuse  epistaxis. 
The  false  membrane  may  spread  up  the  lachrymal  duct,  and  form  on 
the  conjunctiva,  or,  obstructing  the  flow  of  tears,  cause  epij)hora.  If 
the  false  membrane  extends  into  the  Eustachian  tube,  there  will  occur 
ear-ache,  noises  in  the  ears,  deafness,  etc.  Extension  downward  into 
the  larynx  may  take  place  early  in  the  disease — from  the  third  to  the 
sixth  day — or  it  may  not  occur  until  the  end  of  the  second  week. 
Laryngeal  diphtheria  is  more  apt  to  occur  in  young  children  and  in 
old  persons  (Oertel).  The  formation  of  false  membrane  may  begin  in 
and  be  limited  to  the  larynx. f     The  capacity  of  the  larynx  being 

*  Reynolds's  "  System  of  Medicine,"  article  "  Diphtheria,"  vol.  i,  American  edition, 
by  Lea. 

\  "  Relation  of  Membranous  Croup  and  Diphtheria,"  "  Medico-Chirurgical  Transac- 
tions," vol.  lii,  p.  7.  "  The  evidence  before  the  committee  is  conclusive  as  to  the  fact 
that  in  epidemics  of  diphtheria  eases  do  occur  in  which  the  false  membrane  is  thus  lim- 
ited ....  but  such  cases  are  exceptional." 


744  MIASMATIC   DISEASES. 

greater  in  adults  than  it  is  in  children,  the  symptoms  of  stenosis  are  more 
pronounced  in  the  latter.  Progressive  difficulty  of  breathing,  a  hoarse, 
then  toneless  voice,  the  characteristic  "  croupy  cough,"  are  the  symptoms 
of  laryngeal  diphtheria.  These  cases  present  the  clinical  history  of 
croup  throughout,  and  the  reader  is  referred  to  the  article  on  that 
topic  for  the  details.  These  cases  do  not  continue  very  long,  and 
their  termination  is  usually  fatal,  although  recoveries  do  ensue.*  They 
prove  fatal  by  spasm  of  the  glottis,  by  obstruction  of  the  bronchi,  by 
pneumonia,  by  carbonic-acid  poisoning,  etc.  In  the  rare  cases  tenni- 
nating  in  recovery,  the  false  membrane  is  expelled  by  coughing,  and 
no  new  membrane  is  produced.  The  fever  and  other  symjstoms  sub- 
side with  the  improvement  in  the  local  condition. 

Septic  Form. — During  the  cou.rse  of  the  catarrhal  or  croupous  form, 
especially  the  latter,  the  products  of  decomposition  entering  the  blood, 
the  condition  of  septicaemia  will  be  produced.  The  development  of 
the  systemic  state  is  preceded  by  ichorous  decomposition  of  the  exu- 
dations and  secretions  of  the  fauces  ;  a  foul-smelling  and  very  irritat- 
ing fluid  is  discharged  from  the  mouth  ;  the  lips  are  eroded  by  it,  and 
on  the  erosions  grayish-white  patches  of  false  membrane  form.  Nu- 
merous capillary  haemorrhages  occur  ;  the  blood  mixing  with  the  de- 
composing membranes  gives  them  a  blackish  appearance  ;  and  the 
whole  mass,  putrefying,  presents  a  strong  likeness  to  gangrene,  but  on 
removing  the  decomposing  materials  the  mucous  membrane  beneath  is 
seen  to  be  merely  hyperaemic,  and  capable  of  entire  restoration.  The 
glands  of  the  neck  and  the  neighboring  connective  tissue  swell  enor- 
mously, and  present  a  shining  appearance,  and  are  hard  or  doughy  to 
the  touch.  When  the  blood  is  poisoned,  the  constitution  sympathizes 
profoundly.  The  face  has  a  sallow,  earthj^,  and  pallid  hue  ;  the  pulse 
is  small,  weak,  compressible,  and  very  slow  ;  the  temperature  does 
not  pass  above  100°,  and  is  more  frequently  at  98°,  even  lower  ;  the 
appetite  is  gone,  nausea,  vomiting,  and  diarrhoea  are  usually  present, 
the  stools  having  a  foul  odor  ;  the  urine  is  small  in  quantity  and 
loaded  with  albumen  ;  and  the  strength  is  exhausted.  Meanwhile  the 
mental  condition  is  that  of  apathy,  the  mind  acting  slowly  but  cor- 
rectly, the  intelligence  becoming  clouded  only  at  the  last.  In  other 
cases,  the  development  of  the  septicaemia  occurring  more  slowly,  the 
phenomena  are  virtually  the  same — the  main  features  being  exhaus- 
tion, slow  and  irregular  pulse  (40  or  50  beats  to  the  minute)  or 
becoming  rapid  and  thready,  the  temperature  below  normal  (96°  or 
97°  Fahr.),  and  weakness  so  great  that  fainting  ensues  on  attempts 
to  sit  up,  death  usually  occurring  suddenly  from  failure  of  the  heart. 
Recovery,  it  is  claimed  (Oertel),  has  been  observed,  but  death  is  the 

*  "  The  mortality  from  this  complication  is  alone  very  great ;  it  has  been  estimated 
that  one  half  of  the  fatal  cases  of  diphtheria  die  from  this  accident "  (Squire,  op.  cit., 
p.  67). 


DIPHTHERIA.  Y45 

usual  result  in  a  day  or  two  after  the  development  of  the  septi  cajmia, 
and  very  rarely  later  than  four  or  five  days  after.  When  recovery 
is  to  take  place,  the  pulse  gains  in  volume,  force,  and  frequency,  the 
temperature  rises,  and  the  local  condition  improves.  Convalescence 
is  necessarily  very  slow. 

Gangrenous  Form. — This  is  an  extension  only  of  the  septica?mic 
form,  and  should  be  so  regarded.  Gangrene  attacks  the  infiltrated 
mucous  membrane,  and  the  exudations  participate  in  the  process.  The 
affected  parts  turn  black,  and  emit  a  horrible  fetor.  Before  separation 
of  the  sloughs  takes  place,  the  blood  is  poisoned,  and  the  patient  rapidly 
passes  into  a  condition  of  profound  adynamia.  Death  is  produced  by 
thromboses,  embolisms,  failure  of  the  heart,  etc. 

Course,  Duration,  and  Termination. — The  course  and  behavior  of 
diphtheria  have  been  sufficiently  detailed  in  the  preceding  pages.  The 
several  forms  described  are  based  on  sound  observation  and  experience, 
which  must  always  be  confirmed.  The  mortality  of  diphtheria  varies 
greatly  in  different  epidemics,  and  the  results  of  sporadic  cases  are  in- 
fluenced by  numerous  causes.  In  some  epidemics  nearly  all  have  died. 
A  mortality  of  one  in  three,  one  in  seven,  and  one  in  ten,  has  been 
observed  in  various  English  epidemics.  So  great  is  the  variety  in  the 
severity  of  epidemics  and  of  individual  cases,  that  no  precise  statement 
of  mortality  rates  can  be  made.  It  is  certainly  true  that  no  case  of 
diphtheria  should  be  regarded  as  trifling,  for  during  the  course  of  the 
simplest  cases  the  most  formidable  symptoms  may  ai'ise.  The  prog- 
nosis in  any  case  is  the  graver,  the  more  virulent  the  case  from  which 
the  poison  was  obtained.  The  age  and  constitution  of  the  individual 
attacked  are  of  moment,  for  the  mortality  is  much  greater  in  young 
children,  both  on  account  of  the  danger  of  laryngeal  implication  and 
their  feeble  powers,  and  in  those  of  any  age  who  possess  poor  con- 
stitutions, are  scrofulous,  and  enfeebled  by  bad  habits  and  hygiene. 
The  appearance  of  successive  deposits,  the  occurrence  of  albuminuria, 
and  the  enlargement  of  the  cervical  lymphatics,  indicate  an  extension 
of  the  disease.  Extension  to  the  larynx,  as  has  already  been  pointed 
out,  is  in  the  highest  degree  unfavorable,  and  especially  so  in  young 
subjects.  Extension  to  the  nasal  passages  is  regarded  as  very  unfavor- 
able, both  on  account  of  the  greater  danger  of  septic  infection  and 
the  interference  with  respiration.  Jacobi,  of  New  York,  who  is  high 
authority,  maintains  that  the  unfavorable  prognosis  of  nasal  diphtheria 
heretofore  made  must  be  modified,  if  proper  treatment  is  instituted. 
Much  vomiting  and  purging  are  unfavorable  symptoms,  and  in  the  same 
way  must  bleeding  be  regarded.  If  the  specific  gravity  of  the  urine 
declines,  and  casts  and  blood-corpuscles  are  present,  the  temperature 
also  rising,  these  symptoms  are  unfavorable.  If  the  temperature  should 
rise  after  the  fifth  day,  it  is  suggestive  of  some  new  development,  or  of 
an  extension  of  the  exudation,     A  low  temperature,  below  normal,  a 


7J:6  MIASMATIC  DISEASES. 

cold  and  clammy  skin,  and  a  slow  and  irregular  pulse,  are  of  particularly 
evil  import.  Cases  that  are  apparently  doing  well  sometimes  tei'mi- 
nate  very  unexpectedly  and  suddenly  by  paralysis  of  the  heart.  As 
regards  the  different  forms  of  diphtheria,  the  catarrhal  is  the  most 
hopeful  ;  next  the  croupous,  and  lastly  the  gangrenous.  A  majority 
of  the  catarrhal  end  in  recovery — of  the  croupous  in  death. 

SequelSB. — Although  the  paralyses  of  diphtheria  are  really  modes  of 
manifestation  of  the  poison,  and  are  referable  to  changes  occurring  in 
nerve  and  muscle,  it  will  be  most  convenient  to  study,  together,  those 
which  occur  during  the  existence  of  the  other  symptoms,  and  those 
which  appear  after  the  supposed  termination  of  the  disease.  The 
latter  group  of  paralyses  come  on  two,  three,  even  six  weeks  after 
the  healing  of  the  mucous  membrane,  but  the  former  arise  to  com- 
plicate the  case  during  the  second  week  and  subsequently.  A  nasal 
tone  of  voice,  some  difficulty  in  swallowing,  and  the  regurgitation 
of  liquids  through  the  nose,  are  first  observed.  At  length,  complete 
inability  to  swallow  occurs  in  the  third  or  fourth  week.  On  inspection, 
the  palate  is  seen  to  hang  limp  and  lifeless,  and  no  movement  is  pro- 
duced by  irritation,  the  sensibility — as  Trousseau  long  ago  pointed 
out — being  absent.  The  power  of  the  heart  is  greatly  reduced  at  the 
same  period  by  extension  of  disease  to  the  motor  apparatus.  The 
slowness  of  the  pulse  sometimes  is  phenomenal,  the  beats  descending 
to  60,  50,  40,  and  in  one  case,  reported  by  Sir  William  Jenner,*  to  16 
per  minute.  Paralysis  of  the  heart  may  take  place  quite  unexpectedly, 
and  without  any  marked  change  in  the  ordinary  conditions  of  the  cir- 
culation. Paralysis  of  the  respiratory  muscles  may  also  occur  at  this 
period,  and  may  involve  the  phrenics  and  diaphragm,  as  in  Sir  William 
Gull's  f  case,  or  the  intercostals  and  other  chest-muscles.  There  is, 
probably,  no  difference,  except  as  to  rate  of  development  and  severity, 
between  the  cases  of  diphtheritic  paralysis  occurring  in  the  second 
week  and  those  which  appear  as  sequelae.  The  latter  pursue  a  nearly 
definite  course.  They  develop  slowly  but  not  until  after  healing  of 
the  mucous  membrane,  and  begin  in  the  muscles  of  the  pharynx  and 
soft  palate,  then  involve  the  ocular  muscles,  and  lastly  the  upper  and 
lower  extremities.  These  paralyses  may  follow  the  mildest  as  well  as 
the  more  severe  cases.  The  author  saw  a  fatal  case  of  diphtheritic 
paralysis  of  the  muscles  of  respii-ation  in  a  lady  of  sixty,  who  had  been 
treated  for  a  simple  sore-throat  two  weeks  before.  Donders  J  men- 
tions the  same  fact  :  "  Among  the  cases  ....  there  were  many  in 
which  the  angina  ran  its  course  without  important  symptoms,  several 
in  which  the  angina  was  not   recognized  as  diphtheria,"  etc.     The 

*  "Diphtheria,  its  Symptoms  and  Treatment,"  p.  44. 
f  London  "Lancet,"  vol.  ii,  18.58,  p.  5. 

X  "  On  the  Anomalies  of  Accommodation  and  Refraction  of  the  Eye  "  (Sydenham 
Society  edition,  p.  607). 


DIPHTHERIA.  1-47 

earliest  to  appear,  and  the  most  usual  paralysis,  is  that  of  the  palatal 
muscles,  causing  the  voice  to  assume  a  nasal  tone,  and  impairing  the 
power  of  deglutition,  especially  for  liquids,  which  are  regurgitated 
largely  by  the  nose.  Ocular  troubles,  consisting  of  dimness  of  vision, 
double  vision,  divergent  and  convergent  strabismus,  dilated  pupil,  dis- 
orders of  accommodation,  etc.,  are  produced  by  paresis  of  the  third, 
fourth,  and  sixth  nerves.  Shortly  after  these  visual  disorders  have 
appeared,  numbness,  tingling,  and  pain  are  felt  in  the  extremities,  no- 
tably the  inferior.  These  perverted  sensations  are  followed  by  paresis 
of  the  muscles  and  awkward  gait,  and  ultimately  paralysis.  The  same 
conditions  obtain  in  the  upper  extremities — they  become  paretic,  then 
paralytic.  The  muscles  are  apt  to  waste,  and  they  lose  their  irritabil- 
ity first  to  the  faradic  and  finally  to  the  galvanic  current,  and  there  is 
more  or  less  anaesthesia  of  the  plantar  surface.  Remarkable  variations 
in  the  extent  of  the  muscular  weakness  are  observed  from  day  to  day 
— a  group  of  muscles  not  paralyzed  to-day  may  be  so  to-morrow,  and 
vice  versa.  The  muscles  of  the  larynx  are  attacked  not  usually  at  the 
same  time  with  those  of  the  pharynx,  as  might  be  expected,  but  when 
there  is  a  wider  diffusion  of  the  paralytic  symptoms.  It  may  be  par- 
tial, affecting  only  one  vocal  cord,  or  general,  affecting  both  cords. 
There  may  be  coincident  ansesthesia  of  the  mucous  membrane.  The 
voice  is  hoarse,  husky,  or  wanting  ;  the  breathing  is  troubled  if  special 
effort  is  necessary  ;  and  the  anaesthesia  may  permit  foreign  bodies  to 
enter  the  glottis,  with  fatal  consequences.  Paralysis  of  the  neck-mus- 
cles and  of  the  thorax  is  apt  to  occur  simultaneously,  an  example  of 
which  is  reported  by  Sir  William  Gull.*  When  this  form  of  paralysis 
occurs,  the  head  can  not  be  supported,  the  respiration  is  shallow,  and  the 
least  effort  induces  dyspnoea.  If  not  soon  relieved,  the  consequences  are 
very  serious  :  the  blood  is  not  decarbonized,  hypostatic  congestion  oc- 
curs, mucus  accumulates,  and  death  happens  in  asphyxia.  The  sphinc- 
ters of  the  rectum  and  bladder  are  usually  paralyzed  with  the  lower 
extremities,  and  anaphrodisia  also  is  produced.  Fortunately,  diphthe- 
ritic paralysis  is  very  amenable  to  treatment,  and  only  from  five  to  ten 
per  cent,  of  the  cases  prove  fatal.  A  cure  is  usually  effected  in  a  few 
weeks,  but  a  case  of  general  paralysis  may  last  a  number  of  months. 
A  fatal  result  is  caused  by  suffocation — the  dropping  of  food  into  the 
glottis  ;  by  pneumonia,  set  up  by  the  entrance  of  some  foreign  body 
into  the  lungs  ;  by  failure  of  respiration  ;  by  paralysis  of  the  heart  ; 
or  by  some  intercurrent  disease. 

Diagnosis. — The  catarrhal  variety  of  diphtheria  may  be  confounded 
with  acute  follicular  ulceration  of  the  tonsils,  and  this  mistake  is  doubt- 
less frequently  made.  The  systemic  condition  may  be  much  the  same 
in  the  two  diseases,  but  the  local  appearances  are  very  different.  In 
the  tonsillar  affection,  there  are  usually  several  ulcers  at  the  orifices  of 

*  Supra. 


'^48  MIASMATIC  DISEASES. 

as  many  follicles,  depressed  below  the  surface  and  containing  a  gray- 
ish, cheesy  secretion.  Pain  is  limited  to  the  affected  tonsil,  and  the 
lymphatics  under  the  angle  of  the  jaw  are  a  little  swollen  and  some- 
what tender.  Both  tonsils  may  be  affected  when  the  same  conditions 
obtain  on  the  other  side.  In  diphtheria  the  exudation  is  on  the  surface 
of  the  membrane,  is  not  limited  to  the  tonsil,  and  is  accompanied  by 
swelling  of  the  deep  cervical  lymphatics.  The  identity  or  non-identity 
of  croup  and  diphtheria  is  still  suh  JucUce.*  It  seems,  however,  defi- 
nitely established  that  there  are  cases  in  which  a  false  membrane  is  lim- 
ited to  the  larynx  and  trachea,  occurring  idiopathically  and  in  the  pro- 
portion of  about  one  to  thirty  during  an  epidemic  of  diphtheria.  That 
a  membranous  laryngitis  can  exist  quite  irrespective  of  diphtheria  is 
rendered  probable  by  analogy  :  there  are  a  membranous  bronchitis 
and  a  membranous  enteritis.  The  fact  of  its  actual  occurrence  is  ad- 
mitted by  Bretonneau,  except  that  he  regards  it  as  diphtheria  of  the 
larynx.  Judged  from  the  clinical  standpoint,  croup  differs  from  diph- 
theria in  being  a  local  affection,  not  contagious  ;  the  exudation  non- 
specific and  formed  on  the  surface  of  the  mucous  membrane  ;  in  that 
it  does  not  cause  systemic  infection,  and  is  not  accompanied  by  albu- 
minuria. The  author  for  these  reasons  adheres  to  the  non-identity  of 
croup  and  diphtheria.  Between  scarlatinal  sore-throat  and  diphtheria 
close  analogies  exist,  but  they  may  be  differentiated  by  reference  to 
these  points  :  in  scarlatina  there  is  an  intense  and  diffused  redness  of 
the  whole  mucous  membrane — in  diphtheria  the  redness  is  merely 
about  the  infected  area  ;  in  scarlatina  the  exudation  is  on  the  surface 
of  both  tonsils  and  usually  also  on  the  palate,  and  is  soft  like  curds — 
in  diphtheria  the  exudation  commences  at  one  or  more  spots,  is  attached 
to  the  epithelium  and  is  of  a  grayish-yellow  or  brownish  color  ;  in  scar- 
latina, the  symptoms  are  violent — convulsions,  delirium,  vomiting,  in- 
tense fever,  inaugurating  the  disease — in  diphtheria  the  symptoms  are 
not  so  severe — there  are  no  convulsions,  delirium,  etc.,  and  only  mod- 
erate fever  ;  in  scarlatina  the  peculiar  rash  appears  at  the  end  of  the 
first  and  beginning  of  the  second  day,  and  which  desquamates — in 
diphtheria  there  is  no  proper  eruption,  only  transient  rashes  which  are 
very  irregular  and  accidental. 

Treatment. — If  the  theory  of  a  local  infection  followed  by  systemic 
poisoning  be  adopted,  the  early  detection  and  destruction  of  the  first 
patch  of  false  membrane  is  of  the  highest  importance.  Bretonneau 
acted  up  vigorously  to  the  requirements  of  his  theory,  and  applied 
muriatic  acid  to  the  patches  as  they  appeared.  This  practice  is  still 
pursued  by  many — by  the  majority  of  physicians,  probably,  but  in  a 
modified  form.     Strong  solutions  of  nitrate  of  silver  ;  the  tincture  of 

*  The  facts  collected  by  the  committee  of  the  Medico-Chirurgical  Society  for  their 
"  Report  on  the  Relations  of  Membranous  Croup  and  Diphtheria  "  are  very  strong  and 
very  ably  presented.     ("  Medico-Chirurgical  Transactions,"  vol.  Ixii,  1879.) 


DIPHTHERIA.  Y49 

the  chloride  of  iron  ;  solution  of  equal  parts  of  perchloride  and  gly- 
cerine ;  solutions  of  salicylic  acid,  of  chloral,  of  chlorate  of  potassa,  of 
borax,  etc.,  are  those  most  usually  employed.  The  objections  to  the  use 
of  strong  caustic  applications  seem  insurmountable.  Experience  has 
shown  that  the  morbid  process  can  not  be  arrested  by  the  most  pi'ompt 
and  efficient  applications,  for  it  is  impossible  to  penetrate  to  all  the 
parts  where  germs  may  be  deposited  ;  injury  done  to  the  healthy  mu- 
cous membrane  invites  the  spread  of  the  false  membrane  ;  the  de- 
struction of  one  layer  of  false  membrane  does  not  prevent  the  repro- 
duction of  successive  layers,  and  it  is  probable  systemic  infection  takes 
place  during  the  period  of  incubation.  Those  who  employ  the  most 
po.werful  applications  do  not  present  better  results.  Cleanliness  of 
the  parts,  frequent  removal  of  decomposing  materials,  and  disinfection 
of  the  discharges,  are  of  great  importance  for  the  prevention  of  septi- 
csemia.  These  observations  are  especially  true  of  diphtheria  of  the 
nose,  the  mortality  from  this  being  largely  due  to  neglect  of  cleanli- 
ness and  disinfection.  Oertel  *  has  abandoned  and  condemns  all  the 
strong  applications  above  mentioned,  and  relies  on  the  vapor  of  hot 
water  containing  a  little  salt,  or  chlorate  of  potassa,  as  the  means  for 
securing  cleanliness,  disengagement  of  the  false  membrane,  and  for 
inducing  suppuration.  The  nares  should  be  carefully  syringed  out 
every  three  or  four  hours  with  a  weak  solution  of  chlorine,  chlorate  of 
potassa,  carbolic  acid,  salicylic  acid  and  borax,  etc.  The  solutions  must 
be  very  weak,  and  used  freely  and  frequently.  With  the  spray  douche 
a  stream  of  vapor  can  be  nearly  constantly  kept  playing  on  the  parts. 
Various  disinfectant  solutions  may  be  used  in  this  way.  The  author 
has  seen  excellent  results  from  the  frequent  application  of  a  solution 
of  lactic  acid — strong  enough  to  taste  sour — by  means  of  a  mop.  A 
quantity  of  this  may  be  applied  by  a  large  mop  to  the  fauces,  and  by 
a  syringe  to  the  nares.  By  what  means  soever  the  result  is  accom- 
plished, careful  washing  of  the  affected  parts  is  necessary.  After- 
ward thei'e  should  be  thoroughly  dusted  over  the  affected  region 
washed  sulphur,  which  is  best  accomplished  by  an  insufflator.  The 
good  effects  of  this  practice  are  undoubted,  and  the  explanation  is  not 
far  to  seek,  A  portion  of  the  sulphur  is  oxidized,  and  sulphurous  acid 
produced.  The  application  of  lime-water  by  a  method  originating 
in  domestic  practice  is  deserving  of  high  commendation.  It  consists 
essentially  in  the  inhalation  of  the  vapor,  as  it  arises  from  the  slaking 
of  lime.  Some  pieces  of  freshly  burned  lime  are  put  into  water,  and 
the  vapor  is  directed  to  the  throat  and  nose,  and  inhaled.  Above  all 
other  topical  applications,  according  to  some  good  authorities,  is  the 
atomization  of  a  maximum  solution  of  muriate  of  quinine,  used  as  often 
as  possible,  the  spray  directed  into  the  fauces.    In  the  case  of  laryngeal 

*  Ziemssen's  "  Clycopaedia,"  article  "Diphtheria,"  op.  cit. 


750  MIASMATIC  DISEASES. 

implication,  an  attempt  should  be  made  to  dissolve  the  false  membrane 
by  very  frequent  inhalation  of  atomized  lime-water  and  lactic  acid. 
Emetics  are  also  used,  to  effect  the  mechanical  displacement  of  the 
membrane.  Those  acting  promptly  and  producing  no  after-depression 
are  the  most  suitable  for  this  purpose,  as  alum,  subsulphate  of  mer- 
cury, sulphate  of  zinc,  ipecac,  but  not  tartar  emetic. 

The  treatment  of  the  systemic  condition  is  equally  important  with 
the  local.  There  are  two  principal  indications — to  limit  the  spread  of 
the  local  disease,  and  to  prevent  systemic  infection.  The  author  has  em- 
ployed, with  apparently  great  advantage,  for  the  first  object,  bromide  of 
ammonium  (two  to  fifteen  grains  every  three  hours).  The  bromides  are 
eliminated  in  large  part  by  the  mucous  surfaces,  especially  of  the  mouth 
and  throat,  and  thus  act  locally  on  the  very  soui'ce  of  mischief.  Act- 
ing similarly,  and  in  a  high  degree  efficient,  is  iodine.  In  the  normal 
state  very  decided  irritation  of  the  fauces  is  produced  by  the  iodides. 
In  diphtheria  the  author  prescribes  the  iodide  of  ammonium  with  the 
bromide  for  the  purpose  of  effecting  a  modification  of  the  morbid  pro- 
cess in  the  fauces.  To  prevent  systemic  infection  it  is  preferable  to 
administer  liquor  iodinil  compositus — one  to  five  drops  every  four 
hours.  Carbolic  acid  may  be  given  with  iodine  (IJ.  Liq.  iodinii  comp. 
3  ij,  acid,  carbol.  3  j.  M.  Sig.  One  fourth  of  a  drop  to  two  drops  in 
water  every  four  hours).  The  most  efficient  of  the  agents  to  prevent 
systemic  infection,  and  at  the  same  time  act  as  a  food,  is  alcohol.  There 
are  those  who  maintain  that  alcohol  is  of  itself  sufficient,  if  only  a 
large  enough  quantity  can  be  given.  From  half  an  ounce  to  an  ounce 
every  three  hours  is  sometimes  administered  to  infants  by  the  advocates 
of  an  exclusively  alcoholic  treatment.  It  is  certainly  good  practice  to 
commence  with  moderate  doses  of  whisky  or  brandy  at  the  onset  of 
the  disorder,  and  increase  them  as  circumstances  demand,  as  the  case 
progresses.  It  is  certainly  surprising  to  observe  the  large  amount 
which  can  be  taken  by  even  the  tenderest  subject.  That  it  is  proving 
beneficial  is  shown  by  an  improvement  in  the  force,  rhythm,  and  fre- 
quency of  the  pulse,  by  rise  in  the  temperature  if  below,  by  a  fall  in 
the  temperature  if  much  above  noi*mal,  and  by  a  change  for  the  better 
in  the  general  state.  Quinia  is  often  given  with  alcohol  for  the  pur- 
pose of  support,  and  as  an  antipyretic  when  the  temperature  is  high. 
The  use  of  quinia  by  atomization  has  been  briefly  referred  to.  It  is 
questionable  whether  the  good  effects  apparently  produced  by  this 
mode  of  application  were  due  to  the  systemic  or  local  action  of  the 
quinine,  for  much  of  that  reaching  the  fauces  is  swallowed.  Kot  only 
stimulants  and  quinia,  but  nourishing  aliments,  are  required  in  this 
disease  from  the  beginning.  Milk,  beef-essence,  egg-nogg,  etc.,  must 
be  given  systematically,  and  when  collapse  is  threatened  the  intervals 
between  the  feedings  must  be  short.  Those  who  have  personal  charge 
of  a  diphtheritic  patient,  and  the  physician,  need  to  exei'cise  great  cir- 


CEREBRO-SPINAL   MENINGITIS.  751 

cumspection  to  avoid  infection.  Several  physicians  have  lost  their 
lives  by  catching  matter  from  the  throat  in  inspecting  the  parts,  by 
clearing  the  canula  used  in  a  tracheal  fistula,  and  by  making  autopsies. 
Whenever  a  case  occurs  in  a  family,  it  should  be  at  once  isolated.  All 
the  dejections,  expectorated  matters,  and  utensils  used  about  the  pa- 
tient should  be  immediately  disinfected  ;  clothing  and  linens  used  dur- 
ing the  illness  should  be  destroyed  ;  and  the  furniture  and  floors  should 
be  washed  v^^ith  chloride-of-zinc  solution,  papering  removed  and  de- 
stroyed, carpets  disinfected  by  heat,  etc.  The  author  was  personally 
cognizant  of  the  following  facts :  A  family  consisting  of  father,  mother, 
two  children,  and  a  nurse,  were  put  into  rooms  of  a  great  hotel  in  Sar- 
atoga that  had  just  been  vacated  by  a  family  returning  home,  of  whom 
several  loere  ill  toith  some  affection  of  the  throat  /  in  a  week  the  little 
boy  became  affected  with  severe  diphtheria,  was  removed  to  another 
and  a  larger  room,  where  he  died  ;  and  into  this  room  some  new-comers 
were  put  the  day  following  the  removal  of  the  dead  body,  without  any 
change  in  the  bed  or  furniture  !  How  many  more  victims  we  do  not 
know.  The  paralytic  affections  of  diphtheria  require  iron  and  quinia, 
the  phosphates,  a  generous  diet,  and  a  change  of  air.  If  they  do  not 
yield  and  get  well  under  these  measures,  special  stimulants  of  the  ner- 
vous system  are  then  necessary.  Strychnia  should  be  given — hypoder- 
matically  if  the  case  is  obstinate — and  the  muscles  should  be  first  ex- 
ercised with  the  galvanic  current,  slowly  interrupted,  and  with  the 
faradic  current  when  the  contractility  of  the  muscle  to  the  latter  has 
been  recovered.  When  paralysis  of  the  muscles  of  respiration  has  oc- 
curred, prompt  application  of  these  remedies  becomes  necessary.  The 
pneumogastric,  the  phrenic,  and  the  intercostal  nerves  must  be  galvan- 
ized in  turn  by  currents  of  considerable  strength,  and  the  diaphragm 
should  be  brought  directly  within  the  circuit  by  poles  placed  on  oppo- 
site sides.  The  question  of  tracheotomy  in  laryngeal  diphtheria  is 
still  sub  judice.  The  mortality  is  so  large  after  this  operation,  as  per- 
formed in  this  country,  only  as  a  dernier  ressort,  that  there  is  a  grow- 
ing disinclination  to  its  performance.  In  France  it  is  performed  earlier, 
with  better  results.  Nevertheless,  the  successful  issue  of  some  ap- 
parently desperate  cases,  such  as  those  of  Mr,  Lawson  and  Mr.  Pugin 
Thornton,  encourages  further  efforts  in  this  dii-ection.* 

CEREBRO-SPINAL   MENINGITIS— CEREBRO-SPINAL    FEVER. 

Definition. —  Cerebrospinal  fever  is  an  acute,  infectious  disease, 
which  prevails  as  an  epidemic,  and  occurs  also  in  the  sporadic  form, 

*  "Transactions  of  the  Clinical  Society,"  vol.  xii,  pp.  117,  122,  "Cases  of  Trache- 
otomy in  the  Last  Stage  of  Diphtheria — Recovery."  For  an  elaborate  discussion  of  the 
subject,  see  Dr.  J.  Solis  Cohen's  work  on  the  throat;  also,  "British  Medical  Journal," 
April  10,  1880. 


752  MIASMATIC   DISEASES. 

and  is  characterized  by  symptoms  of  excitation,  followed  by  symptoms 
of  depression  of  the  cerebro-spinal  functions,  by  various  forms  of  erup- 
tions on  the  skin  and  by  fever  of  moderate  grade — the  symptoms  being 
dependent  on  an  inflammation  of  the  membranes  of  the  brain  and 
spinal  cord.  It  has  received  various  designations — as  spotted  fever, 
epidemic  meningitis  {^tiWe),  petechial  fever  (G.  B.  Wood).  Cerebro- 
spinal meningitis  is  the  term  most  generally  used,  and  cerebro-spinal 
fever  is  that  proposed  in  the  "  Nomenclature  of  Diseases." 

Causes. — Cerebro-spinal  meningitis  prevails  under  the  most  opposite 
conditions  of  climate  and  soil,  and  at  all  seasons  ;  but  certain  parts  of 
the  globe  have  not  as  yet  been  visited — Asia,  Australia,  and  Africa, 
except  Algiers,  having  escaped.*  Epidemics  appear  simultaneously  in 
districts  widely  separated,  under  circumstances,  as  to  soil,  climate,  and 
hygienical  surroundings,  the  most  diverse.  While  these  facts  are  true, 
it  is  also  evident  that  season  has  some  slight  influence,  not  directly, 
but  indirectly,  through  the  changes  in  habits  and  modes  of  life  imposed 
by  climate.  The  disease  prevails  more  during  the  winter  and  spring, 
a  fact  which  is  true  of  the  epidemics  in  this  country  and  other  places. 
Local  conditions,  good  or  bad  hygiene,  or  station  in  life,  are  without 
influence  in  its  causation.  The  disease  selects  by  preference  the  young, 
especially  young  men,  but  no  age  and  neither  sex  are  exempt.  Young 
recruits,  the  boys  of  a  boarding-school,  children,  male  and  female, 
under  fifteen,  are  favorite  victims,  while  the  disease  becomes  rapidly 
less  and  less  frequent  after  twenty-five.  There  is  probably  much  truth 
in  Hunt's  f  observation  that  this  disease  "  has  its  favored  habitat  in 
cold,  damp,  and  overcrowded  tenements,  preferring  prisons  and  bar- 
racks," as  respects  its  appearance  among  troops.  The  author  witnessed 
an  epidemic  among  the  boy  inmates  of  a  military  school,  most  favor- 
ably situated  as  respects  the  known  hygienic  conditions,  and  there  was 
no  extension  of  the  disease  in  the  surrounding  rather  thickly  populated 
neighborhood.  "  In  April,  1863,  four  cases  occurred  in  a  single  tent 
of  the  Twenty-second  North  Carolina  :  three  of  these  cases  died,  all 
being  from  one  family  of  conscripts,  while  the  fourth  tent-mate,  an  old 
soldier,  recovered.  It  is  difiicult  to  define  any  special  circumstances 
affecting  this  tent  in  preference  to  the  others,"  says  Dr.  Robinson, 
who  reports  the  incident.  A  great  many  examples  have  now  been  col- 
lected of  outbreaks  within  very  limited  areas,  as  in  jails,  prisons,  indi- 
vidual houses,  confined  to  such  areas,  while  simultaneously  similar  out- 
breaks are  occurring  at  distant  points.  It  is  supposed  that  the  places 
visited  are  in  a  bad  hygienic  state,  but  there  must  be  some  other  ele- 
ment present,  for  the  nurture  and  development  of  which  evil  hygienic 
influences  are  necessary.     There  must  be  a  peculiar  miasm,  materies 

*  Lombard,  "  Traite  de  Cliraatologie  Medicale,"  op.  cif.,  vol.  iv. 

f  "  United  States  Sanitary  Commission  Memoirs,"  edited  by  Flint,  chap,  ii,  on  "  Cere- 
bro-spinal Meningitis,"  by  Dr.  Sanford  B.  Hunt,  p.  383. 


CEREBRO-SPINAL   MENINGITIS.  753 

morbi,  or  germ  present.  The  nature  of  this  unknown  principle  has  not 
as  yet  been  ascertained.  The  etiological  facts  thus  far  presented  de- 
monstrate that  the  disease  is  not  contagious  in  the  proper  meaning  of 
the  term.  That  it  is  infectious  there  can  be  no  reasonable  doubt.  Dr. 
Burdon-Sanderson  *  concludes  that  it  is  not  contagious  ;  that  there  were 
no  instances  of  spread  from  the  family  first  attacked ;  that  the  disease 
appeared  simultaneously  in  the  two  districts,  which  were  thirty  miles 
apart ;  that  in  no  instance  were  two  persons  attacked  in  one  house.  Dr. 
Lidell  f  says  that  "  no  relation  by  contact  whatever  can  be  traced  be- 
tween them,"  in  the  cases  occurring  in  Stanton  Hospital.  The  general 
experience  of  American  physicians,  as  collected  by  Stille,  X  is  against 
contagion,  in  the  sense  that  small-pox  is  contagious. 

Patliological  Anatomy. — The  changes  wrought  by  this  disease  are 
almost  as  distinctive  as  those  of  typhoid  fever.  They  are  chiefly  in 
the  cerebro-spinal  axis.  The  skin  after  death  presents  traces  of  the 
herpetic  eruptioits  which  are  usually  seen  during  life.  There  are  ex- 
tensive suggillations,  not  confined  to  the  dependent  parts  only,  and  large 
patches  of  ecchymoses,  the  body  in  some  instances  being  almost  black 
(Stille).  The  2)ost-morte)7i  rigidity  is  strongly  marked,  the  muscles,  in 
cases  that  have  continued  for  many  weeks,  being  much  emaciated. 
Besides  emaciation  the  muscles  are  found  to  have  undergone  granular 
degeneration  to  a  greater  or  less  extent.  The  dura  mater  and  arach- 
noid may  be  but  little  altered,  but  usually  present  traces  of  hypersemia, 
the  arachnoid  rough  and  opaque  also.  The  pia  mater  is  always  con- 
gested, often  intensely  punctated  with  capillary  hsemorrhages,  and 
thick  and  opaque  by  reason  of  interstitial  exudations.  After  the  ini- 
tial hypersemia,  wandering  leucocytes  in  great  numbers  are  found  in 
the  neighborhood  of  the  vessels,  and  these  are  the  only  changes  seen 
in  the  fulminant  form,  because  there  has  not  been  suflicient  time  to 
develop  others.  After  a  day  or  two,  the  subarachnoid  spaces  contain 
more  or  less  cloudy  serum,  sometimes  reddish  from  the  presence  of  red 
blood-corpuscles.  Next,  the  membrane  is  infiltrated  by  an  exudation 
composed  for  the  most  part  of  purulent  elements  having  a  greenish  or 
yellowish  color  ;  the  exudation  may  be  more  consistent,  firmer,  and  of 
a  gelatinous  character.  Dr.  Burdon-Sanderson  found  that  the  gelati- 
nous material  consisted  of  cells  having  many  points  of  resemblance  to 
but  still  differing  from  pus-corpuscles,  and  that  the  interstitial  sub- 
stance was  crowded  with  granules.  The  exudation  may  be  several 
lines  in  thickness,  and  it  is  found  in  greatest  abundance  along  the 
great  vessels  in  the  fissure  of  Sylvius,  about  the  optic  chiasm,  infun- 

*  "  Official  Report  on  the  Epidemic  of  Cerebro-spinal  Meningitis  of  Northern  Germany," 
London,  1865. 

f  "American  Journal  of  the  Medical  Sciences,"  January,  1865,  p.  1,  toI.  xlix. 

I  "  Epidemic  Meningitis ;  or.  Cerebrospinal  Meningitis,"  by  Alfred  Stille,  M,  D., 
Pliiladelphia,  Lindsay  k  Blakiston,  1867,  p.  178. 

48 


Y54  MIASMATIC   DISEASED 

dibulum,  pons,  and  cerebellum.  The  whole  convexity  of  the  hemi- 
spheres may  be  covered,  but  usually  here  the  exudation  is  most  abun- 
dant in  the  sulci  between  the  convolutions.  As  regards  the  visceral 
arachnoid,  which  is  usually  more  or  less  thickened  and  opaque,  Klebs  * 
has  found  that  this  change  is  due  to  purulent  iniiltration.  Similar 
structural  alterations  are  found  in  the  membranes  of  the  spinal  canal. 
The  dura  mater  sometimes  presents  the  same  character  of  changes  as 
in  recent  pachymeningitis  (Klebs,  s.  333),  at  least  the  haemorrhagic 
extravasation  ;  the  arachnoid  is  more  or  less  cloudy  from  infiltration 
with  pus-cells  ;  but  the  most  important  of  the  alterations  are  those  in 
the  pia,  which  is  strongly  adherent  to  the  cord  at  all  points.  As  in  the 
brain,  the  first  morbid  appearance  consists  in  hyperaemia,  and  then 
serum,  pus,  gelatinous  exudation  of  greater  or  less  thickness,  the  nerve- 
roots  entirely  covered  with  a  thick  layer  of  exudation,  follow  in  order 
according  to  the  time  given  to  them.  It  follows,  then,  that  in  the  ful- 
minant form,  death  occurring  in  a  few  hours,  there  may  be  but  little 
evidence  in  the  spinal  canal  of  the  severity  of  the  malady.  The  ravages 
of  this  disease  are  not  limited  to  the  membranes.  The  ventricles  con- 
tain more  or  less  turbid  serum,  the  ependyma  and  the  choroid  plexus 
are  hyperasmic,  and  there  may  be  more  or  less  of  the  purulent  exuda- 
tion. Those  portions  of  the  brain  and  spinal  substance  adjacent  to 
the  pia  mater  are,  in  advanced  cases,  altered  by  hyperaemia  and  by  the 
imbibition  of  fluids,  so  that  the  nerve-elements  are  more  or  less  disas- 
sociated (Klebs).  In  cases  of  long  standing,  the  effusion  may  be  so 
great  as  to  cause  flattening  of  the  convolutions  arid  cedema  of  the 
brain.  In  one  case  the  central  canal  of  the  cord  was  filled  with  pure 
pus  (Ziemssen).  Besides  these  post-mortetn  appearances  which  are  ne- 
cessary to  constitute  the  disease,  various  alterations  have  been  found, 
and  some  of  them  so  constantly  as  to  justify  the  opinion  that  they  are 
parts  of  the  morbid  complexus.  The  heart-muscle,  as  it  is  in  other 
fevers,  is  soft,  friable,  and  granular  in  the  cases  of  some  weeks'  dura- 
tion, but  unaltered  in  the  fulminant  form.  The  blood  is  dark,  fluid, 
wanting  in  coagulability,  and  the  walls  of  the  vessels  are  stained  by 
it.  The  lungs  frequently  present  evidences  of  bronchitis,  catarrhal 
pneumonia,  atelectasis,  etc.  The  hepatic  cells  and  the  tubular  epithe- 
lium are  cloudy  and  more  or  less  granular  by  deposit  of  fat-granules 
(Klebs),  a  change  which  is  likened  to  that  which  takes  place  in  phos- 
phorus-poisoning. 

Symptoms. — There  are  marked  differences  in  the  behavior  of  cases 
of  cerebro-spinal  meningitis,  but  they  may  be  comprehended  in  four 
groups  :  the  ordinary  or  common  form  ;  the  fulminant  ;  the  petechial ; 
and  the  abortive. 

T7ie  Comjnon  Form. — Almost  always  the  disease  begins  abruptly, 

*  "Zur  Pathologie  der  opidemiscben  Meningitis,"  von  Dr.  Klebs  in  Berlin,  Virchow's 
"  Archiv,"  xxxiv,  s.  32*7,  et  seq. 


CEREBRO-SPIXAL   MENIXGITIS.  755 

and  if  pi'odromes  exist  tliey  are  headache,  muscular  pains,  vertigo,  and 
fatigue,  which  disappear  just  as  the  disease  is  about  to  manifest 
itself.*  A  chill,  or  a  decided  sense  of  chilliness,  an  intolerable  head- 
ache, nausea,  vomiting,  vertigo,  and  an  overwhelming  sense  of  weak- 
ness and  illness,  are  the  formidable  symptoms  with  which  the  disease 
opens.  The  pain  in  the  head  may  be  like  a  constricting  band,  especially 
about  the  forehead,  or  a  boring  or  lancinating  pain  shooting  in  all  di- 
rections, or  the  whole  head  is  the  seat  of  an  intense  but  indescribable 
anguish.  With  every  attempt  to  rise  up,  vertigo  comes  on  and  vomit- 
ing is  induced,  but  when  recumbent  the  vertigo  often  persists,  the 
patient  seizing  hold  of  the  bed  to  keep  steady.  The  vomiting  is 
causeless  so  far  as  the  stomach  is  concerned ;  at  first  food  and  after- 
ward some  mucus  and  bilious  matter  come  up.  In  a  few  hours  the 
muscles  of  the  neck  become  somewhat  stiff,  and  pain  is  experienced 
with  every  attempt  to  turn  the  head.  An  extension  of  this  state  of 
the  cervical  muscles  takes  place  to  the  muscles  of  the  spinal  column, 
which  become  stiff,  rigid,  and  painful  with  all  attempts  to  move  the 
body.  The  muscles  of  both  upper  and  lower  extremities  are  affected 
in  the  same  way,  and  the  motions  of  flexion  and  extension  are  both 
painful  and  awkwardly  performed.  At  the  same  time  symptoms  of 
irritation  of  sensory  nerves  are  experienced.  The  surface  of  the  body 
generally  is  highly  sensitive,  but  the  skin  of  the  temples,  neck  and  face 
is  esj)ecially  so,  a  light  jDinch  causing  expression  of  suffering  even 
when  insensibility  is  profound.  Headache  is,  however,  the  source  of 
greatest  suffering,  which  is  manifest  by  restlessness  and  groaning 
during  the  existence  of  more  or  less  complete  insensibility.  At  the 
outset  high  mental  excitement  introduces  delirium  ;  in  children,  con- 
vulsions may  occur  ;  the  delirium  may  be  active,  maniacal,  the  patient 
difficult  of  restraint,  or  it  may  assume  a  busy,  trembling  character. 
The  symptoms  of  excitation  in  the  mental  sphere  do  not  continue  long:, 
for  effusion  which  occurs  in  the  course  of  the  first  day  causes  depres- 
sion of  this  function,  and  the  excitement  or  delirium  gives  place  to 
somnolence  or  stupor.  The  rigidity  of  the  neck  increases,  and,  the 
spinal  muscles  also  contracting,  the  head  is  drawn  back  and  the  spine 
curved  ;  the  forearms  are  partly  flexed  on  the  arms,  the  legs  on  the 
thighs.  In  the  milder  cases  there  is  a  condition  of  somnolence,  from 
which  the  patient  may  be  aroused  and  will  answer  correctly  in  part, 
but  he  at  once  falls  into  stupor,  or  the  state  of  somnolence  is  inter- 
spersed with  paroxysms  of  active  delirium.  Besides  the  condition 
of  rigidity  of  the  muscles  generally,  attacks  of  cramp  and  transient 
spasms  occur.  Convulsions  at  the  outset  in  the  case  of  children  have 
already  been  referred  to,  but  the  cramps  and  spasms  here  intended 

.  *  Githens  says  that  "  there  is  a  week  of  prodromata,"  "American  Journal  of  Medical 
Sciences,"  July,  1867,  '' Xotcs  of  Ninety-eight  Cases  of  Epidemic  Cerebro-spinal  Menin- 
gitis," etc.,  by  W.  H.  H.  Githens,  M.  D. 


75(5  MIASMATIC   DISEASES. 

occur  in  groups  of  muscles — cramps  in  the  muscles  of  the  legs  chiefly, 
and  spasmodic  tvritchings  in  the  muscles  of  the  lips,  eyelids,  etc.  The 
face  is  usually  pale  and  sunken,  the  features  fixed,  sometimes  re- 
tracted (risus  sardo7iici(s),  and  always  expressive  of  suffering,  mani- 
fested in  the  deepest  stupor.  The  special  senses  are  more  or  less  dis- 
ordered. Intolerance  of  light  is  succeeded  by  double  vision,  amblyopia, 
and,  in  some  cases,  amaurosis  ;  tinnitus  aurium,  vertigo,  and  intoler- 
ance of  sounds,  are  succeeded  by  impaired  hearing,  in  many  cases  by 
permanent  deafness.  Taste  is  lost,  appetite  is  absent,  and  vomiting  is 
frequent.  Constipation  exists  at  the  first  part  of  the  disease,  but 
toward  the  close  diarrhcea  and  involuntary  evacuations  occur.  The 
tongue  becomes  very  dry  and  cracked  j  sordes  accumulate  about  the 
teeth,  some  blood  exudes  from  the  gums  and  nares,  and  the  hardened 
clots  block  up  the  anterior  nares  and  collect  about  the  teeth.  It  not 
imfrequently  happens  that  lumbrici  are  thrown  up  in  vomiting.  It  is 
remarkable  how  little  the  circulatory  system  participates  in  the  inflam- 
matory disturbance  of  the  nervous  system.  The  pulse  is  usually  a 
little  quickened,  but  it  does  n.ot  exceed  100  as  a  rule  within  the 
first  four  or  five  days  ;  but  very  distinctive  features  are  the  irreg- 
ularity of  the  pulse,  the  unaccountable  quickening,  the  equally  unac- 
countable slowing,  and  the  variations  in  tension.  The  respiration  is 
equally  iiTegular — at  first  quickened,  and  afterward  becoming  variable 
in  respect  to  the  depth  and  rhythm.  "When  sufiicient  effusion  occurs  to 
compress  the  medulla — in  from  three  to  five  days — the  respiration  as- 
sumes the  well-known  Cheyne-Stokes  type — is  sighing  and  irregular. 
Various  kinds  of  eruption  appear  on  the  body,  but  these  are  not 
observed  in  every  epidemic,  although  it  is  our  observation  that  some 
form  of  eruption  will  be  found  if  careful  search  be  made.  Herpetic 
eruptions  are  most  frequent,  next  roseola  and  urticaria — all  eruptions 
belonging  to  the  group  of  trophic  affections,  and  petechite,  those  due 
to  disintegration  of  the  blood.  The  most  frequent  site  of  the  herpes 
is  on  the  face,  but  it  may  occur  on  any  part,  while  the  others  are  dis- 
tributed over  the  body  irregularly.  Having  attained  its  maximum  in 
from  three  to  six  days,  the  case  may  take  either  of  two  directions 
— to  a  fatal  termination  ;  to  recovery.  In  the  fatal  cases  the  stupor 
deepens  into  profound  coma  ;  the  symptoms  of  motor  and  sensory  exci- 
tation yield  to  those  of  depression  ;  the  rigidity  and  contraction  relax  ; 
the  extremities  become  limp  and  paralyzed  ;  the  paralysis  may  be  gen- 
eral or  limited  to  one  side  ;  the  pupils  are  dilated  and  motionless,  the 
eyes  deeply  sunken  and  surrounded  by  a  dark  ring  ;  no  noise  awakens 
a  reponse  ;  deglutition  is  slowly  and  at  last  not  at  all  performed  ;  the 
evacuations  are  involuntary  ;  the  temperature  rises  in  some  cases  to 
105°,  106°,  even  108°,  and  the  pulse  beats  too  rapidly  to  be  counted 
In  the  cases  taking  the  other  direction,  the  symptoms  of  depression  are 
necessarily  slight  and  transient,  for  any  considerable  depression  indi- 


CEREBRO-SPINAL   MENINGITIS.  Y57 

cates  an  amount  of  damage  done  by  the  effusion  such  as  to  be  incom- 
patible with  recovery.  In  the  favorable  cases  the  rigidity  of  the  neck 
and  spine  gradually  subside,  but  do  not  entirely  disappear  for  some 
time  after  recoA^ery  ;  the  vomiting  ceases  ;  the  headache  subsides  but 
does  not  entirely  disappear,  and  the  strength  is  slowly  regained.  From 
the  well-marked  cases,  as  just  described,  to  the  abortive  form,  there  are 
numerous  gradations  in  severity.  During  every  epidemic,  and  also  of 
those  occurring  sporadically,  many  of  the  cases  are  very  mild.  In 
such  examples  we  observe  the  sudden  onset,  considerable  headache, 
stiffness  of  the  muscles,  but  little  or  no  delirium,  and  no  symptoms  of 
depression. 

The  Fuhninant  Form. — In  this  form  we  find  the  poison  in  its 
most  active  condition.  The  patients  are  struck  down  in  the  midst  of 
full  health,  and  pass  in  a  few  hours  into  a  state  of  collapse.  There  is 
usually  a  severe  chill ;  the  patient  becomes  cyanosed  ;  the  skin  grows 
cold,  and  is  covered  with  a  clammy  sweat ;  the  face  shrinks,  and  is 
livid  ;  the  eyes,  surrounded  with  black  rings,  sink  deeply  in  their  orbits  ; 
intense  pain  is  at  first  felt  in  the  head,  but  in  a  short  time  conscious- 
ness is  lost,  preceded  by  brief  delirium  ;  respiration  is  slow,  labored, 
and  sighing  ;  the  pulse  is  rapid,  feeble,  and  soon  ceases  at  the  wrist ; 
purpuric  blotches  appear  on  various  parts  of  the  body,  which  some- 
times quickly  vesicate  and  slough  ;  the  urine  is  scanty,  and  loaded  with 
albumen.  Such  cases  prove  fatal  in  a  few  hours  or  in  a  few  days. 
Fortunately,  they  have  occurred  less  frequently  in  the  later  epidem- 
ics, and  are  rare,  if  not  unknown,  in  the  sporadic  form. 

The  Petechial  Form. — This  differs  from  the  ordinary  form,  in  the 
greater  tendency  which  the  cases  exhibit  toward  dissolution  of  the 
blood.  Bleeding  takes  place  from  the  gums  and  nares,  and  extravasa- 
tions occur  under  the  skin  at  various  points,  forming  petechise  and 
vibices.  In  the  severest  cases  of  this  form,  the  symptoms  are  extreme 
from  the  beginning,  there  are  great  prostration,  extensive  purpuric 
patches,  vibices,  and  ecchymoses,  coma  appears  early,  and  a  fatal  re- 
sult is  reached  in  three  or  four  days.  In  the  lighter  cases,  the  only 
departure  from  the  course  of  the  ordinary  form  is  the  occurrence  of 
numerous  and  extensive  ecchymoses  and  vibices,  and  of  haemorrhages 
from  the  mucous  surfaces.  The  mortality  has  apparently  not  been  the 
greater  by  reason  of  this  preponderance  of  the  purpuric  spots. 

Tlie  Abortive  Form,  consists  in  the  occurrence  of  headache,  stiff 
neck  and  spine,  vomiting,  without  fever,  in  those  who  are  much  ex- 
posed to  the  disease,  as  mothers,  nurses,  physicians,  etc.,  but  are  not 
susceptible  further  than  this  to  the  action  of  the  poison.  The  malady 
in  this  abortive  form  does  not  require  confinement  to  bed,  and  ceases, 
without  further  development,  in  two  or  three  days.  Writers  (Ziems- 
sen)  also  describe  an  interm^ittent  form,,  but  there  are  no  differences 
really  between  this  and  the  ordinary  form  ;  for  the  range  of  tempera- 


758  MIASMATIC   DISEASES. 

ture  is  so  irregular  that  no  typical  thermal  line  can  be  drawn  for  this 
disease. 

Course,  Duration,  and  Termination. — None  of  the  acute  infectious 
diseases  present  such  irregularities  in  their  course  as  cerebro-spinal 
meningitis.  From  the  course  of  the  fulminant  form  to  that  of  the 
ordinary  form  with  the  usual  complications  and  the  protracted  conva- 
lescence, diversified  by  relapses,  there  is  an  enormous  difference  in 
point  of  duration.  While  the  former  occupies  from  four  or  five  hours 
to  two  or  three  days,  the  latter  continues  four  weeks,  six  weeks,  three 
months,  according  to  the  behavior  of  the  several  stages.  The  severe 
cases  of  the  ordinary  form  terminate  in  from  one  to  two  weeks.  Cases 
that  are  very  protracted  usually  terminate  in  recovery,  although  vari- 
ous disabilities  may  remain,  but  deaths  have  occurred  in  the  sixth  or 
seventh  week  (Rad cliff e  *).  The  mortality  has  varied  greatly  in  dif- 
ferent epidemics,  from  eighty  to  twenty  per  cent.  It  seems  to  be  estab- 
lished that  the  general  mortality  is  declining,  rather  than  increasing, 
although  some  recent  statistics  place  it  at  almost  the  highest  point.  In 
a  late  Massachusetts  epidemic  the  mortality  was  a  little  over  sixty-one 
per  cent.,  and  in  the  last  Philadelphia  epidemic  it  was  thirty-three  per 
cent.  (Stille).  During  the  same  year  the  mortality  at  Hardwicke  Hos- 
pital, Dublin,  was  eighty  per  cent.  (Radcliffe).  The  sporadic  cases  are 
as  a  rule  much  less  severe  than  those  during  an  epidemic.  The  sever- 
ity of  the  disease  is  increased  by  various  complications,  and  the  recov- 
ery hindered  by  sequelae.  The  most  important  of  these  complications 
is  broncho-pneumonia  and  albuminuria.  As  regards  sequelae,  every 
epidemic  leaves  behind  sad  examples  of  the  ravages  committed  in  the 
brain  and  organs  of  sense.  One  of  the  most  usual  cerebral  affections 
left  by  the  disease  is  chronic  hydrocephalus.  After  the  cessation  of 
the  inflammation,  morbid  products,  contracting  and  solidifying,  com- 
press the  vena  Galeni  and  the  straight  sinus  ;  the  ependyma  undergoes 
considerable  thickening,  and  the  fluid  in  the  ventricles  increases.  Flat- 
tening of  the  convolutions  and  atrophy  of  the  brain  are  the  results. 
In  the  cases  which  have  come  under  the  author's  notice,  the  head  was 
large,  the  mind  weak,  the  skull  apparently  thin,  the  eyes  prominent, 
the  extremities  paretic,  and  the  muscular  acts  incoordinate.  Headache 
is  a  pretty  nearly  constant  symptom  ;  but,  at  intervals  which  are,  how- 
ever, not  regular,  paroxysms  occur  in  which  intense  headache,  vomit- 
ing, vertigo,  and  prolonged  stupor  with  delirious  intervals  occur ; 
sometimes  there  are  convulsions,  unconsciousness,  and  involuntary 
evacuations,  or  there  may  be  merely  severe  headache,  intolerance  of 
light  and  sound,  vertigo,  and  vomiting.  If  the  interval  between  the 
seizures  is  long,  considerable  improvement  may  take  place  in  the  gen- 
eral health,  and  expectations  of  recovery  may  be  entertained.    Usually 

*  Dr.  J.  Netten  Radcliffe,  Reynolds's  "  System,"  article  "  Cerebro-spinal  Meningitis," 
American  edition,  H.  C.  Lea's  Son  &  Co.,  1880. 


CEREBRO-SPINAL  MENINGITIS.  Y59 

death  takes  place  in  one  of  the  seizures,  or  the  patient  may  be  cut  off 
by  some  intercui-rent  disease.  Recovery  very  rarely  ensues,  if  possible 
at  all.  Partial  recovery  is  not  uncommon — the  mind  being  weak,  the 
special  senses  impaired,  members  paralyzed  and  deformed.  Paralysis 
of  cranial  nerves,  hemiplegia,  defects  of  speech,  etc.,  are  results  of 
cerebro-spinal  meningitis  produced  by  the  organization  of  the  exuda- 
tion, the  pseudo-membrane  causing  injury  of  parts  by  pressure.  The 
special  senses  are  very  frequently  permanently  damaged.  The  eye  is 
injured  by  a  simultaneous  suppurative  inflammation,  and  by  the  ex- 
tension of  the  inflammation  along  the  sheath  of  the  oj)tic  nerve.  Iritis, 
choroiditis,  retinitis,  opacities  of  the  cornea,  are  the  most  important. 
The  auditory  nerve  is  readily  injured,  owing  to  its  softness  of  texture  ; 
hence  we  may  suppose  the  frequency  with  which  impaired  hearing  re- 
sults, but  inflammation  of  the  internal  and  middle  ear  often  occurs  si- 
multaneously with  the  inflammation  of  the  meninges.  Further,  inflam- 
mation may  extend  by  contiguity  of  tissue  along  the  sheath  of  the 
auditory  nerve.  The  result  is  that,  in  a  large  proportion  of  cases,  dull- 
ness of  hearing  to  deafness  is  found  to  exist  after  the  termination  of 
the  disease. 

Diagnosis. — Cerebro-spinal  meningitis  may  be  confounded  with 
tubercular  meningitis  and  typhoid  fever.  The  distinction  between 
tubercular  and  epidemic  meningitis  rests  on  these  points  :  the  former 
is  always  sporadic  ;  is  preceded  by  prodromic  symptoms  ;  its  course  is 
marked  by  decided  crises  ;  the  rhythm  of  the  pulse  and  respiration  is 
much  disturbed,  and  there  are  no  eruptions.  As,  however,  the  same 
tissue  is  involved  and  by  an  analogous  process,  it  need  not  occasion 
surprise  that  these  diseases  present  very  similar  symptoms.  The  dif- 
ferentiation from  typhoid  rests  on  these  points  :  typhoid  comes  on 
more  slowly,  is  without  the  intense  headache,  the  muscular  rigidity, 
and  the  causeless  vomiting  of  meningitis  ;  in  typhoid  there  is  diar- 
rhoea— in  meningitis,  constipation  ;  in  typhoid  there  are  some  hebe- 
tude of  mind,  muttering  delirium,  stupor — in  meningitis,  active  delirium 
terminating  in  coma,  or  stupor  interspersed  with  delirium  ;  in  typhoid 
there  is  a  typical  thermal  line — in  meningitis  there  is  no  regular 
course  to  the  fever  ;  in  typhoid  the  disease  develops  slowly  to  its 
maximum — in  meningitis  the  maximum  is  reached  in  four  or  five  days; 
in  typhoid  thei'e  is  a  characteristic  rose-colored,  lenticular  eruption — 
in  meningitis  there  are  various  kinds  of  eruptions,  pursuing  no  definite 
plan. 

Treatment. — The  accumulated  experience  of  the  medical  profession 
seems  now  to  indicate  the  superiority  of  opium  as  a  remedy  for  cere- 
bro-spinal meningitis.  The  author  has  witnessed  some  striking  exam- 
ples of  its  value,  especially  in  the  form  of  morphia  hypodermatically. 
In  Germany  it  holds  the  first  place  (Ziemssen).  In  various  epidemics, 
Boudin  has  found  opium  the  only  remedy  worthy  of  confidence.    Stille 


760  MIASMATIC  DISEASES. 

strongly  advocates  its  employment.  There  are  two  points  in  regard 
to  the  administration  of  opium,  on  which  the  author  strongly  insists — 
early  and  efficient  administration.  It  should  anticipate  the  effusion 
by  an  antagonistic  action  on  the  vessels.  To  accomplish  this  object, 
large  doses  of  morphia  are  necessary,  for,  as  every  observer  has  wit- 
nessed, there  are  a  remarkable  increase  of  the  arterial  tension  and  slow- 
ing of  the  heart  produced  by  a  full  dose  ;  and  these  are  the  conditions 
most  necessary  to  prevent  migration  of  the  white  corpuscles.  Aside 
from  theoretical  considerations,  it  has  been  observed  that  there  is  a 
singular  tolerance  of  opium  in  this  disease.  A  decided  effect  should 
be  produced,  and  the  quantity  necessary  must  be  prescribed.  The 
period  when  opium  or  morphia  may  be  most  useful  is  limited  by  the 
effusion  ;  after  the  first  four  or  five  days  it  is  less  important,  but  its 
utility  does  not  cease  until  the  symptoms  of  depression  come  on. 
Quinia  and  ergot  have  both  been  largely  used  in  this  country,  with 
and  without  opium,  but  the  evidence  in  favor  of  these  remedies  is  not 
satisfactory.  If  there  is  active  delirium,  fluid  extract  of  gelsemium 
(one  to  five  drops  every  two  to  four  hours)  is  useful  in  allaying  excite- 
ment. When  the  period  of  depression  approaches,  quinia,  carbonate 
of  ammonia,  and  especially  turpentine,  which  is  more  particularly  in- 
dicated when  the  skin  is  relaxed  and  cold,  are  the  most  useful  reme- 
dies. Although  ice-bags  and  cold  applications  are  much  advised  for 
the  head  and  spine,  the  author  holds  that  they  do  mischief  by  the 
de^Dression  of  the  circulation  which  they  cause.  He  advises  instead, 
the  use  of  hot  water  applied  by  a  sponge,  passed  over  the  spine 
every  two  or  three  hours.  If  there  is  constipation,  a  mercurial  pur- 
gative may  be  given,  but  the  best  authorities  condemn  the  use  of 
mercury  to  procure  absorption  of  the  inflamed  products — a  bit  of  Eng- 
lish practice  lately  revived  in  Germany.  On  the  other  hand,  iodide  of 
potassium  has  been  used  with  success  to  remove  adventitious  prod- 
ucts after  the  acute  attack  has  subsided.  The  success  of  this  mea- 
sure will  be  promoted  by  the  frequent  application  of  a  hot  douche  to 
the  spine,  flying-blisters,  and  the  passage  of  a  weak,  continuous  gal- 
vanic current,  but  not  until  all  local  disease  has  wholly  subsided.  As 
this  disease  is  marked  by  great  depression  of  the  vital  powers,  stimu- 
lants are  needed  early,  but  they  should  not  be  given  recklessly.  When 
the  pulse  becomes  stronger  and  more  regular  under  their  use,  they 
do  good  ;  but,  if  the  tongue  grows  dry  and  the  delirium  more  excit- 
ing, they  do  mischief.  A- generous  diet  is  required  from  the  outset. 
Milk,  eggs,  beef-juice,  mutton-broth,  etc.,  should  be  given  every  three 
hours,  day  and  night,  to  avoid  paroxysms  of  weakness  in  the  early 
morning. 


INFLUENZA.  761 

INFLUENZA— EPIDEMIO   CATARRH. 

Definition. — Influenza  is  a  specific  epidemic  disease,  self-limited, 
characterized  by  catarrh  of  the  respiratory  organs,  and  sometimes  of 
the  digestive,  and  by  nervous  symptoms  and  debility. 

Causes. — Epidemics  of  influenza  have  appeared  from  early  in  the 
sixteenth  century  until  the  nineteenth.  Parkes,  however,  traces  back 
epidemics  to  the  ninth  century.  The  usual  duration  of  an  epidemic  is 
two  to  four  years,  during  which  the  whole  habitable  globe  may  be 
visited.  An  epizootic,  similar  in  all  respects  to  the  epidemic  in  the 
human  family,  has  occasionally  prevailed  as  widely  among  horses. 
Influenza  occurs  in  all  climates  and  latitudes,  and  visits  on  its  rounds 
all  countries  in  both  hemispheres  ;  but  it  may  limit  its  ravages  to  one 
hemisphere,  or  to  a  single  country.  The  rate  of  its  progress  varies  : 
thus  Europe  has  been  gone  over  in  six  weeks  by  one  epidemic — in  six 
months  by  another.  The  rate  of  spread  varies  as  much  in  particular 
countries  visited,  and  a  month  has  been  consumed  in  the  extension  of 
the  epidemic  influence  from  London  to  Edinburgh  (Parkes).  As  it 
prevails  under  all  conditions  of  soil  and  climate,  and  is  not  contagious, 
there  must  be  present  some  morbific  principle  in  the  atmosphere. 
That  it  is  a  minute  organiscn  is  a  theory  which  best  explains  the  facts 
connected  with  the  spread.  During  several  epidemics  it  has  been  ob- 
served that  various  kinds  of  fungi  flourished  in  unusual  abundance. 
There  is  no  regular  period  of  incubation,  but  attacks  occur  immedi- 
ately on  exposure,  and  in  other  cases  not  for  some  days.  One  attack 
does  not  procure  an  exemption  from  future  ones. 

Pathological  Anatomy. — The  changes  of  structure  proper  to  this 
disease  are  limited  to  the  broncho-pulmonary  mucous  membrane.  An 
intense  hypergemia  takes  place  in  the  nasal,  pharyngeal,  laryngeal, 
tracheal,  and  bronchial  mucous  membrane.  The  hypersemia  is  usually 
confined  to  the  larger  tubes,  but  it  may  extend  to  the  finer  tubes,  so 
that  atelectasis  may  be  associated  with  it.  Pneumonia,  both  croupous 
and  catarrhal,  are  occasional  complications.  In  a  portion  of  the  cases 
the  gastro-intestinal  mucous  membrane  is  also  strongly  hypergemic, 
and  a  quantity  of  watery  or  thick  viscid  mucus  is  produced,  but  this 
seems  accidental.  Doubtless,  changes  in  the  blood  and  in  the  ner- 
vous system,  of  a  very  subtile  kind,  must  take  place,  for  those  occur- ' 
ring  in  the  respiratory  tract  are  not  adequate  to  explain  the  nervous 
symptoms  and  the  evidences  of  blood-poisoning. 

Symptoms. — The  onset  of  the  disease  is  sudden.  There  may  be 
a  decided  chill,  or  chilliness  alternating  with  flushing  and  heat,  and 
fever  at  once  comes  on,  soon  rising  to  the  maximum,  but  in  other  cases 
the  febrile  symptoms  develop  slowly,  and  do  not  attain  their  maximum 
until  two,  three,  or  even  four  days.  The  course  of  the  fever  is  remit- 
tent, the  exacerbations  occurring  at  night.     With  the  rise  of  tempera- 


Y62  MIASMATIC   DISEASES 

ture  there  is  an  increase  in  tlie  pulse,  the  number  of  beats  approximat- 
ing 100,  At  the  same  time  a  severe  headache,  located  in  the  frontal 
sinuses  and  extending  into  the  eyes,  is  experienced.  Soon  after  the 
rise  of  temjDerature,  in  respect  to  which  all  observers  are  agreed,  the 
symptoms  of  an  acute  catarrh  come  on  :  there  occur  heat,  stuffing, 
dryness,  quickly  followed  by  increased  secretion,  and  sometimes  epis- 
taxis  ;  the  conjunctivae  are  injected,  and  the  eyes  are  watery  ;  present- 
ly the  throat  feels  hot,  dry,  and  irritated,  and  spots  like  measles  are 
to  be  seen  on  the  palate  ;  the  mucous  membrane  of  the  mouth  and 
tongue  are  also  hypersemic,  but  less  so  than  the  fauces.  Soon  the  voice 
grows  husky  ;  a  troublesome  cough,  and,  after  a  time,  abundant  thin, 
acrid  mucus,  and  afterward  purulent  exj^ectoration,  are  brought  up,  but 
at  first  the  cough  is  hard,  dry,  and  tormenting,  especially  in  the  even- 
ing and  at  night,  and  occasionally  vomiting  is  excited  by  it.  At  first 
there  is  almost  incessant  sneezing,  but  this  subsides  as  the  secretions 
increase.  As  the  catarrh  descends  into  the  respiratory  organs,  the 
symptoms  grow  more  serious.  The  expectoration  may  become  bloody; 
more  or  less  dyspnoea  is  experienced  by  many,  and  sharp  stitches  are 
felt  in  the  sides  ;  sibilant  and  sonorous  rales  are  audible  over  the  tubes, 
and  the  signs,  rational  and  jDhysical,  of  pneumonia  or  pleuritis  may  be 
added  to  those  of  the  disease  j)roper.  Instead  of  this  gradual  progres- 
sion of  the  symptoms  from  above  downward,  the  nasal,  pharyngeal, 
laryngeal,  and  tracheal  mucous  membrane  may  be  affected  simultane- 
ously. In  ordinary  cases  the  catarrh  reaches  its  maximum  on  the  sec- 
ond, third,  or  fourth  day,  and  then  declines,  ceasing  after  some  days 
longer.  As  the  symptoms  develop  along  the  respiratory  tract,  in  a  por- 
tion of  the  cases  the  gastro-intestinal  mucous  membrane  is  affected.  At 
fii'st  the  oesophagus  is  attacked,  then  the  membrane  below.  The  appe- 
tite is  gone,  there  is  a  good  deal  of  nausea,  and  vomiting  occurs  sjDon- 
taneously,  or  is  excited  by  the  cough  or  by  the  presence  of  food.  The 
epigastrium  is  painful  and  there  are  colicky  pains  ;  sometimes  diar- 
rhoea occurs — sometimes  there  is  obstinate  constipation.  A  remarkable 
phase  of  this  disease  consists  in  the  disturbance  of  the  nervous  sys- 
tem, which  is  quite  out  of  proportion  to  the  gravity  of  the  local  dis- 
ease or  to  the  amount  of  fever.  From  the  beginning  the  patients 
appear  anxious  and  depressed,  and  are  weak,  unequal  to  any  exertion, 
and  confused  by  any  attempt  at  mental  effort.  There  are  general 
muscular  pains  and  soreness,  flying  pains  along  the  course  of  the  prin- 
cipal nerve-trunks,  but  the  chief  source  of  suffering  is  the  frontal  head- 
ache. Besides  the  hebetude  of  mind  observed  to  a  less  or  greater 
extent  in  all  cases,  there  is  sometimes  delirium  ;  in  still  other  cases  a 
remarkable  state  of  somnolence  has  been  noted.  Vertigo  is  present  in 
most  of  the  cases  ;  and  in  some  there  is  a  decided  hyperoesthesia  of  the 
skin  of  the  head  and  neck.  Sweating  is  not  usual  at  first,  and  if  it 
occur  soon  is  significant  of  an  early  subsidence  of  the  fever,  but  it  is 


INFLUENZA,  763 

one  of  the  critical  phenomena  marking  the  termination  of  the  disease. 
When  there  is  much  sweating,  sudamina  are  present.  The  urine  is 
usually  lessened  in  amount  and  sometimes  scanty  or  suppressed.  The 
sweat  is  said  to  be  highly  acid,  and  the  urine  also  acid  and  high-colored. 

Course,  Duration,  and  Termination. — There  are  great  variations  in 
the  intensity  of  epidemics  and  of  individual  cases.  Some  races  suffer 
severely,  others  slightly.  Children  are  less  susceptible,  and  have  the 
disease  more  mildly.  The  weak  and  cachectic  and  the  aged  run 
greater  risks  than  the  robust  and  young.  Uncomplicated  cases  pursue 
their  course  in  from  four  to  eight  days  ;  the  fever  reaches  its  maxi- 
mum on  the  third,  fourth,  or  fifth  day,  and  then  terminates  by  crisis 
or  by  lysis.  The  critical  phenomena  consist  in  a  profuse  sweat,  a  free 
urinary  discharge,  an  attack'  of  diarrhoea,  or  an  epistaxis.  In  the  cases 
declining  by  lysis,  several  days  are  occupied  in  the  return  to  the  nor- 
mal state.  Relapses  are  by  no  means  uncommon.  Cough  and  expec- 
toration due  to  bronchitis  may  persist  for  some  time  after  the  disease  ; 
the  nervous  symj)toms  may  linger  and  delay  convalescence,  or  complica- 
tions may  arise,  or  sequelse  follow  after  the  disease  proper.  Capillary 
bronchitis  and  catarrhal  pneumonia  may  result  by  an  extension  of  the 
morbid  process  from  the  bronchial  tubes.  A  severe  conjunctivitis, 
tonsillitis,  or  laryngitis,  may  develop  from  the  usual  implication  of 
these  parts.  Besides  these  diseases,  which  are  merely  exaggerations  of 
ordinary  lesions,  existing  maladies  may  be  much  aggravated  by  an  in- 
fluenza. Those  so  affected  are  especially  phthisis,  emphysema,  dilated 
heart.  Pregnant  women  attacked  with  influenza  are  apt  to  abort. 
Notwithstanding  its  apparently  profound  impression  on  the  organism 
of  man,  the  poison  of  influenza  is  scarcely  lethal.  The  mortality  of 
the  last  epidemics  has  not  exceeded  two  per  cent,  where  the  disease 
appeared  most  noxious.  Fatal  cases,  when  they  occur,  seem  to  be  due 
to  the  complications  which  arise  in  the  course  of  them  or  to  the  sequelse. 

Treatment. — Repose  in-doors,  a  generous  diet,  and  the  moderate  use 
of  stimulants,  are  the  most  important  measures.  At  the  outset  a  full 
dose  of  quinia  and  morphia  (gr.  xv — gr.  ss.)  exercises  a  favorable  in- 
fluence ;  and  throughout  the  disease  these  are  the  most  useful  reme- 
dies to  quiet  the  harassing  cough  and  to  maintain  the  strength.  If 
there  is  much  secretion,  belladonna  or  its  active  principle,  atropia,  may 
be  combined  with  the  morphia  and  quinia.  If  the  bronchial  mucous 
membrane  is  severely  attacked,  small  doses  of  tartar  emetic,  or  ipe- 
cac and  morphia  are  useful  (I^.  Ext,  ipecac  fl.  3  ij,  tinct,  opii  deodor, 
3  iv,  tinct,  aconiti  rad,  3  i.  M.  Sig,  Six  to  ten  drops  every  two 
hours).  If  the  finer  tubes  are  involved,  the  preparations  of  ammonia, 
the  iodide,  muriate,  and  carbonate  of  ammonia,  should  be  freely  admin- 
istered, .  If  the  stomach  is  very  irritable,  as  is  the  case  in  many  epi- 
demics, the  most  useful  remedies  are  oxalate  of  cerium,  hydrocyanic 
acid,  minute  doses  of  morphia  subcutaneously,  carbolic  acid,  with  or 


764  MIASMATIC   DISEASES. 

without  bismuth,  etc.  For  the  violent  head  symptoms  which  some- 
times ensue,  the  most  approf)riate  remedies  are  bromide  of  potassium, 
gelsemium,  duboisia,  morphia  subcutaneously,  etc.  If  there  is  much 
local  distress,  the  vapor  of  hot  water  should  be  sedulously  inhaled. 
When  the  first  irritation  is  felt  in  the  nares,  a  solution  of  muriate  of 
quinia  should  be  applied  and  allowed  to  pass  through  into  the  fauces, 
after  the  manner  of  Helmholtz.  It  is  probable  that  pilocarpine  will  be 
found  extremely  useful  in  cases  of  influenza,  administered  at  the  out- 
set with  the  view  to  abort  the  malady.  As  a  self -limited  disease  aris- 
ng  from  an  unknown  cause,  it  may  be  safely  left  to  the  resources  of 
nature,  unless  the  rise  of  complications  demands  interference. 


HAT-FEVER— SUMMER   CATARRH. 

Definition. — Hay-fever  is  an  acute  catarrh  of  the  upper  air-pas- 
sages chiefly,  occurring  at  a  fixed  period  annually,  and  disappearing 
after  a  variable  duration.  It  has  received  a  variety  of  designations 
besides  those  above  given,  as  hay-asthma^  rose-told,  June  cold,  au- 
tumnal catarrh,  etc. 

Causes. — Those  who  suffer  from  an  annual  visit  of  hay-fever  refer 
their  malady  to  a  variety  of  causes,  and  it  is  probable  that  various 
kinds  of  emanations  excite  the  disease.  It  is  an  interesting  fact  that 
three  members  of  our  profession,  themselves  sufferers  from  the  disease, 
have  made  the  most  important  contributions  *  to  our  knowledge  of  this 
affection.  By  Dr.  Bostock  the  disease  was  supposed  to  be  of  a  spe- 
cific nature,  and  he  rejected,  from  the  point  of  view  of  his  own  experi- 
ence, the  supposed  agency  of  emanations  from  new-mown  hay  or 
grasses.  Wyman  was  unable  to  come  to  any  conclusion  in  regard  to 
the  supposed  agency  of  minute  organisms,  whether  animal  or  vege- 
table, but  he  has  carefully  indicated  the  geographical  position  of  the 
hay-fever  zones  in  this  country.  Wyman's  attention  was  directed  to 
autumnal  catarrh,  as  this  is  the  form  from  which  he  suffered  ;  on  the 
other  hand,  Bostock  recognized  the  disease  as  it  occurs  in  June. 
Probably  the  most  important  investigation  ever  undertaken  is  that 
of  Blackley,  who  has  shown  that  the  pollen  of  rye  produced  the  most 
violent  symptoms  of  hay-asthma,  notably  sneezing,  profuse  catarrh, 
and  oppressed  breathing,  and  that  the  pollen  of  grasses,  of  wheat,  oats, 
and  barley  was,  next  to  rye,  the  most  active  in  causing  catarrhal 
symptoms.  Further  experiments  showed  that  the  pollen  in  the  atmos- 
phere consisted  in  the  large  proportion  of  ninety-five  per  cent,  of  that 

*  "Autumnal  Catarrh  (Uay-Fever),"  by  Morrill  Wyman,  M.  D.,  1872 ;"  Experi- 
mental Researches  on  the  Cause  and  Nature  of  Catarrhus  JSstivus  (Hay-Fever  or  Hay- 
Asthma),"  by  Charles  H.  Blackley,  London,  1873,  second  edition,  London,  1880.  The 
disease  was  first  described  by  Dr.  Bostock,  giving  his  own  case,  "  Medico-Chirurgical 
Transactions,"  vol.  x,  part  1,  p.  161  ;  also  ibid.,  vol.  xiv,  p.  437,  "  On  Catarrhus  ^stivus." 


HAY-FEVER.  765 

from  the  grasses — the  graminacerB.  That  these  observations  and  the 
conclusions  based  on  them  are  correct,  can  hardly  be  denied.  But  it  is 
probable  that  other  influences  are  also  necessary.  Beard  has  lately  pub- 
lished a  monograph  *  based  on  a  study  «f  two  hundred  cases,  from  which 
it  appears  that  there  are  several  factors  concerned  in  the  production 
of  this  singular  malady.  He  concludes  that  hay-fever  is  essentially  a 
neurosis  ;  that  the  same  form  of  disease  occurs  in  the  spring,  summer, 
and  fall  ;  that  it  is  hereditary,  and  a  product  of  modern  civilization, 
and  that,  when  the  predisi^osition  exists,  various  exciting  causes  may 
develop  the  disease.  We  believe  that  these  propositions  are  correct. 
When  the  neurotic  temperament  is  present,  and  a  special  tendency 
exists,  various  exciting  causes,  as  heat,  dust,  but  especially  the  pollen 
of  grasses,  of  rye,  corn,  and  rag-weed,  may  excite  summer  catarrh. 
Various  cases  have  been  published,  showing  that  a  mental  impression 
may  excite  the  disease.  Phoebus  mentions  a  case  in  which  the  symp- 
toms of  hay-fever  were  excited  in  a  susceptible  patient  by  looking  at 
a  highly  realistic  picture  of  a  hay -field. 

Symptoms. — There  are  two  forms  in  which  the  disease  manifests 
itself — the  catarrhal  and  the  asthmatic — but  they  are  often  united  in 
the  same  individual.  Hay-fever  is  distinctly  periodical  ;  it  occurs  at 
certain  seasons  only,  which  differ  in  different  cases  ;  and,  in  many 
persons,  it  comes  on  with  unfailing  promptitude  on  a  certain  day. 
Whether  it  occur  in  the  spring,  summer,  or  fall,  its  clinical  features 
are  the  same. 

Catarrhal  Form. — There  may  be  warnings  of  the  approach  of  the 
disease  in  a  sense  of  lassitude  and  weariness,  inaptitude  for  exertion, 
loss  of  appetite,  a  coated  tongue,  diarrhoea,  or  constipation,  etc.,  but  in 
a  great  majority  of  cases  the  onset  is  sudden.  In  the  enjoyment  of 
the  usual  health,  the  first  symptoms  are  felt,  although  it  is  true  those 
who  have  had  the  disease  for  years  know  full  well  the  time  of  its  ap- 
proach, and  probably  experience  various  subjective  symptoms,  which 
are  purely  mental  in  origin.  The  first  symptom  is  an  itching  of  the 
eyes,  nose,  behind  the  posterior  nares,  and  the  palate.  This  is  fol- 
lowed by  the  flow  of  a  transparent  serous  fluid,  and  then  sneezing 
begins,  which  is  most  aptly  described  by  Henry  Ward  Beecher,  him- 
self a  sufferer  from  the  disease  :  "  You  never  before  even  suspected 
what  it  really  was  to  sneeze.  If  the  door  is  open,  you  sneeze.  If  a 
pane  of  glass  is  gone,  you  sneeze.  If  you  look  into  the  sunshine,  you 
sneeze.  If  you  sneeze  once,  you  sneeze  twenty  times.  It  is  riot  of 
sneezes.  First  a  single  one,  like  a  leader  in  a  flock  of  sheep,  bolts 
over  ;  and  then,  in  spite  of  all  you  can  do,  the  whole  flock,  fifty  by 
count,  come  dashing  over  in  twos,  in  fives,  in  bunches  of  twenty." 
The  eyes  water,  and  the  conjunctiva  reddens  ;  the  nasal  mucous  mem- 

*  "  Hay-Fever  or  Summer-Catarrh :  its  Nature  and  Treatment,"  Now  York,  Harper 
&  Brothers,  1876,  pp.  266. 


766  MIASMATIC  DISEASES. 

braue  swells  and  becomes  hyperaeinic  ;  and  so  great  is  the  swelling  in 
many  instances  that  the  two  sides  of  the  passageway  approximate, 
and  breathing  is  then  carried  on  by  the  mouth.  When  the  swelling 
occurs,  the  sneezing  is  less  persistent,  or  ceases  altogether ;  the  dis- 
charge which  was  clear  and  watery  becomes  yellowish  and  thicker,  or 
it  may  be  reddish  from  an  admixture  with  blood.  A  very  unpleasant 
sense  of  heat  and  burning  is  felt  about  the  nose  and  eyes,  and  pain, 
which  is  rather  lancinating,  shoots  through  the  orbits  and  frontal 
sinuses,  and  sometimes  into  the  head.  The  throat  is  hot,  dry,  and 
somewhat  swollen,  and,  in  consequence  of  extension  of  the  swelling  to 
the  orifices  of  the  Eustachian  tubes,  the  hearing  becomes  obtuse,  and 
pain  sometimes  is  felt  in  the  ear. 

Asthmatic  Form. — This  begins  at  the  same  time,  and  runs  its  course 
with  the  catarrhal  form,  or,  after  an  uncertain  pei'iod,  succeeds  to  the 
latter.  In  either  case  an  extension  of  the  morbid  process  takes  place 
to  the  larynx  and  bronchial  tubes,  which  become  swollen  and  hyper- 
semic ;  a  hoarse  laryngeal  (croupy)  or  a  wheezy  bronchial  cough 
occurs,  and  asthmatic  difficulty  of  breathing  is  experienced  in  varying 
degrees  of  severity,  from  a  mere  sense  of  constriction  to  extreme  dysp- 
noea. In  the  worst  cases  the  same  phenomena  are  exhibited  as  in 
the  severe  cases  of  asthma  :  the  patient  is  unable  to  lie  down,  struggles 
for  breath,  is  pale,  and  covered  with  a  cold  sweat.  Remissions  occur, 
but  the  difficulty  of  breathing  does  not  entirely  cease  until  the  hay- 
fever  is  over,  and  in  some  subjects  more  or  less  bronchitis,  with  occa- 
sional dyspncea,  persists  for  two  or  three  months  afterward.  Very 
alarming  symptoms  may  arise  from  an  extension  of  the  disease  to  the 
finer  bronchi  (capillary  bronchitis),  or  congestion  of  the  lungs  may 
unexpectedly  occur,  or  an  attack  of  pneumonia  supervene.  Unless 
some  of  these  secondary  diseases  happen,  the  constitutional  symptoms 
are  by  no  means  severe.  The  pulse  is  a  little  accelerated,  the  temper- 
ature slightly,  if  at  all,  elevated,  except  during  and  for  a  short  time 
subsequent  to  the  asthmatic  attacks.  The  strength  is  somewhat  re- 
duced, the  appetite  is  rather  poor,  and  the  discomfort  sufficient  to 
render  a  patient  miserable. 

Course,  Duration,  and  Termination. — The  disease  behaves  in  a 
definite  manner  in  all  cases,  and  comes  on  and  goes  off  with  the 
strictest  regularity.  The  duration  of  individual  cases  is  from  a  few 
days  to  three  months,  the  average  being  about  six  weeks.  As  locality 
is  an  important  element  in  the  causation,  the  behavior  of  cases  is  much 
affected  by  the  surrounding  conditions.  As  a  rule,  if  the  patient 
remain  at  the  same  place,  the  violence  of  the  attacks  rather  increases 
year  by  year.  Those  at  first  assuming  a  merely  catarrhal  form,  after 
a  time  become  asthmatic,  and  in  some  instances  the  author  has  known 
the  asthma  to  become  a  chronic  condition,  and  to  occur  throughout 
the  year.     On  the  other  hand,  timely  removal  from  the  hay-fever  zone 


HAY-FEVER.  Y67 

may  entirely  prevent  seizures.  Although  hay-fever  never  proves  fatal, 
and  usually  leaves  no  sign,  it  may  lead  to  the  development  of  more 
serious  ailments,  as  asthma,  chronic  bronchitis,  impaired  hearing,  etc. 

Treatment. — For  those  who  possess  the  means  to  travel,  there  is 
no  remedy  so  effectual  as  removal  from  the  hay-fever  zone  in  time  to 
prevent  the  attack.  A  sea-voyage,  so  arranged  that  the  patient  is  on 
the  ocean  at  the  time  of  the  attack,  or  residence  in  Europe,  especially 
in  Switzerland,  during  the  same  period,  is  always  effectual.  There 
are  various  parts  of  the  United  States  where  exemption  from  the 
seizures  may  also  be  secured  for  one  or  many  years,  but  the  immunity 
does  not  always  continue  indefinitely.  The  White  Mountains,  the 
Catskills,  the  highest  points  of  the  AUeghanies,  the  Adirondacks,  and 
the  Rocky  Mountains,  are  to  be  recommended.  Many  seashore  places 
can  be  resoi-ted  to  with  confidence  of  relief,  so  long  as  the  breezes  blow 
from  the  ocean  :  Fire  Island  and  the  Isles  of  Shoals  are  among  the 
most  desirable.  Certain  parts  of  Canada,  Mackinaw,  and  Marquette, 
on  the  upper  lakes,  are  suitable  resorts  for  many  cases.  As  no  specific 
has  been  discovered,  the  remedies  are  very  numerous.  As  is  the  case 
in  the  neuroses,  a  remedy  acting  favorably  on  one  occasion  will  usually 
fail  to  relieve  when  employed  again.  Quinia  has  been  more  useful 
than  any  other  agent,  and  may  be  depended  on  to  give  more  or  less 
relief  if  used  efficiently.  Before  the  access  of  the  paroxysm  it  should 
be  administered  in  the  quantity  of  five  grains  three  times  a  day  for  a 
week,  and,  when  the  first  symptoms  of  irritation  of  the  nares  are  felt, 
a  solution  of  the  muriate  (the  most  soluble  salt)  should  be  applied  to 
the  nares.  When  the  disease  has  begun,  the  best. results  are  obtained 
from  full  doses  of  the  iodide  of  potassium— -fifteen  grains  every  four 
to  eight  hours.  If  an  abundant  secretion  is  poured  out,  atropia  will 
be  found  highly  useful.  The  author  has  had  excellent  results  from 
minute  doses  of  morphia  and  atropia  (morphia  sulphate  gr.  -J,  atropia 
sulphate  gr.  -g-J „)  when  the  paroxysm  is  well  advanced.  When  asth- 
matic symptoms  are  experienced,  the  most  useful  remedies  are  iodides 
and  grindelia.  Local  applications  are,  if  rightly  managed,  more  effi- 
cient than  internal  remedies.  Carbolate  of  iodine  may  be  applied  by 
the  post-nasal  syringe  thoroughly  to  the  posterior  nares,  and  by  the 
straight  syringe  through  the  anterior  nares  (1^.  Acid,  carbol.  3  iij, 
tinct.  iodinii  3  v.  M.  Sig.  Add  from  one  to  five  minims  to  a  gill  of 
water).  A  simple  expedient  consists  in  vaporizing  iodine  and  cau- 
tiously inhaling  the  vapor  through  the  nares.  This  may  be  accom- 
plished by  placing  a  few  drops  of  the  tincture  in  a  warm  vial.  Solu- 
tions of  chlorate  of  potash,  of  chloride  of  sodium,  and  of  iodide  of 
potassium,  properly  diluted,  are  also  used  with  effect  by  the  syringe 
and  douche.  Powders,  as  bismuth,  tannin,  iodoform,  etc.,  are  applied 
by  the  insufflator  to  the  nasal  passages,  but,  like  the  remedies  above 
mentioned,  are  uncertain. 


768  MIASMATIC   DISEASES. 

WHOOPING-COUGH— PERTUSSIS. 

Definition. —  Wliooping -cough  is  a  specific  disease,  occurring  chiefly 
in  childhood,  and  once  only  during  life,  and  characterized  by  succes- 
sive forcible  expirations,  and  at  their  termination  by  a  loud,  resounding, 
sonorous  inspiration. 

Causes. — Rosenthal  has  shown  that  irritation  of  the  internal  branch 
of  the  superior  laryngeal  nerve  produces  relaxation  of  the  diaphragm, 
spasm  of  the  glottis,  and  a  convulsive  expiration — the  series  of  acts 
which  constitute  a  paroxysm  of  whooping-cough.  Hence,  we  may 
conclude  that  the  special  exciting  cause  of  this  disease  is  a  contagious 
principle  which  acts  upon  the  respiratory  organs,  with  special  excita- 
tion of  the  filaments  of  the  superior  laryngeal  nerves.  The  nature  of 
this  principle  has  hitherto  escaped  recognition.  The  morbific  mate- 
rial may  excite  the  disease  at  any  age,  but  it  is  most  common  from  the 
first  to  the  seventh  year,  and  it  happens  in  females  more  frequently 
than  in  males.  Pertussis  occurs  among  all  races  and  classes,  and  is 
more  prevalent  in  winter  and  spring,  although  it  is  encountered  at 
other  seasons.  As  epidemics  of  whooping-cough  sometimes  precede, 
accompany,  or  follow  epidemics  of  measles,  a  relationship  has  been 
supposed  to  exist  between  them ;  but  there  is  no  real  foundation  for 
such  an  opinion.  One  attack  removes  the  susceptibility  to  the  disease, 
and  it  is  uncommon  for  a  second  attack  to  occur  in  the  same  individual. 
The  period  of  incubation  is,  probably,  about  ten  days,  but  it  varies 
considerably. 

Pathological  Anatomy. — The  only  lesions  are  hypersemia  of  the 
mucous  membrane  of  the  nares,  pharynx,  larynx,  bronchial  tubes,  etc., 
increased  secretion  after  a  preliminary  dryness  of  the  membrane,  the 
secretion  at  first  consisting  of  transparent  mucus,  afterward  becoming 
more  or  less  j^urulent,  and,  when  this  condition  has  been  reached,  the 
redness  of  the  membrane  is  succeeded  by  paleness  and  anaemia.  Vari- 
ous pulmonary  and  cerebral  lesions  occur  also  during  the  course  of 
whooping-cough,  but  these  are  complications  not  necessary  to  the 
disease. 

Symptoms. — There  are  three  well-defined  stages  of  the  ordinary  or 
common  form  of  the  disease — the  catarrhal,  the  spasmodic,  and  the 
terminal — and  there  is  a  complicated  form.  The  catarrhal  stage  can 
not  be  differentiated  from  an  ordinary  catarrh.  There  occur  coryza, 
more  or  less  cough,  and  slight  fever  with  evening  exacerbation,  and 
moi'ning  remission  or  intermittence,  general  malaise  and  loss  of  ap- 
petite. After  one  or  two  weeks  the  cough  changes  its  character  ;  it 
becomes  more  persistent,  and  assumes  a  somewhat  spasmodic  and 
paroxysmal  character.  As  a  rule  gradually,  but  sometimes  suddenly, 
the  characteristic  whoop  is  heard.  Then  the  paroxysms  have  a  dis- 
tinctive character  :  the  cough  consists  of  a  succession  of  short,  raj^id, 


WHOOPING-COUGH.  Y69 

expiratory  efforts  ;  the  face  gets  red  ;  the  eye.s  swell  and  protrude  ; 
the  body  is  more  and  more  bent  forward  in  the  effort  at  coughing  ; 
then,  when  the  breath  is  entirely  exhausted,  a  deep,  loud,  crowing  in- 
spiration occurs.  During  each  paroxysm  there  may  be  two,  three,  or 
more  of  such  efforts,  and  at  the  expiration  of  them  the  patient  brings 
up  a  quantity  of  tenacious,  glairy  mucus,  which  is  dislodged  with  diffi- 
culty, and  is  often  accompanied  by  vomiting.  In  the  progress  of  the 
case,  the  expiratory  effort  is  less,  the  inspiratory  is  not  so  long  delayed, 
the  secretion  becomes  less  viscid  and  more  purulent,  and  vomiting  oc- 
curs less  frequently.  The  peculiar  whoop  or  sonorous  inspiration  is 
after  a  time  wanting  to  some  of  the  paroxysms,  and  ultimately  ceases 
altogether.  During  the  paroxysm,  the  expiratory  effort  coincides 
with  a  partial  occlusion  of  the  glottis,  the  venous  blood  accumulates, 
»nd  more  or  less  cyanosis  of  the  face  and  head  is  produced  ;  haemor- 
rhage may  occur  from  the  nose,  the  ears,  rarely  from  the  bronchi,  and 
xmder  the  conjunctiva.  The  frequent  collision  of  the  under  surface 
of  the  tongue  with  the  front  teeth  excites  an  ulceration  of  the  fraenum 
and  neighboring  portion  of  the  tongue.  In  some  cases  the  sudden 
compression  of  the  abdominal  organs,  produced  by  the  coughing,  gives 
rise  to  the  formation  of  hernia,  to  prolapse  of  the  bowel,  and  to  invol- 
untary evacuations.  The  duration  of  the  paroxysms  varies  from  a  few 
seconds  to  several  minutes,  and  the  number  of  them,  daily,  is  very  va- 
rious, ranging  from  ten  to  a  hundred,  the  average  being  about  twenty 
or  thirty.  During  the  period  of  maximum  severity,  the  attacks  are 
rather  more  numerous  by  night  than  by  day,  destroying  sleep,  which 
may  ultimately  induce  a  serious  state.  The  frequent  vomiting,  also, 
causes  such  a  loss  of  aliment  that  considerable  weakness  and  emacia- 
tion result.  On  the  other  hand,  when  the  paroxysms  are  widely  sepa- 
rated, the  health  may  be  fairly  well  maintained.  The  action  of  the 
heart  is  very  rapid  during  the  paroxysm,  but  in  the  interval  it  may  be 
normal,  unless  the  system  is  reduced.  The  skin  is  more  or  less  relaxed, 
and  during  a  paroxysm  may  be  covered  with  sweat.  Attacks  are  in- 
duced by  various  causes.  Imitation  is  a  strong  motive  ;  the  presence 
of  food  in  the  stomach  and  the  inhalation  of  dust  or  irritatino-  fumes 
of  any  kind  may  excite  attacks.  When  the  paroxysm  is  about  to  ap- 
proach, the  child  takes  refuge  with  its  nurse,  or  seizes  hold  of  some 
object  of  support,  the  face  turns  pale,  and  then  comes  the  explosion. 

Course,  Duration,  and  Termination.— In  a  well-defined  case  of  the 
ordinary  form  the  course  is  tolerably  uniform.  The  catarrhal  stage 
continues  two  or  three  weeks,  the  spasmodic  three  or  four,  and  the 
terminal  stage  a  week  or  two,  although  it  may  be  prolonged  by  a 
cough  of  habit.  The  course  of  whooping-cough  may,  however,  be 
much  modified  by  the  occurrence  of  complications.  These  occur  chief- 
ly in  the  lungs  and  the  brain.  In  every  severe  case  of  whooping- 
cough  there  is  probably  more  or  less  pulmonary  congestion,  due  to  the 
49 


770  MIASMATIC  DISEASES. 

interference  witli  the  respiration  occasioned  by  the  paroxysms  of 
coughing.  When  this  occurs_  the  breathing  is  more  or  less  oppressed 
in  the  intervals  between  the  paroxysms  ;  the  face  is  constantly  some- 
what cyanosed ;  the  action  of  the  heart  is  quick  ;  the  pulse  is  weak, 
and  the  general  condition  is  depressed.  A  frequent  and  very  fatal 
complication  of  whooping-cough  is  capillary  bronchitis,  with  the  at- 
tendant accidents  of  atelectasis  and  broncho-pneumonia.  Not  unfre- 
quently  these  complications  lead  to  caseous  pneumonia,  emphysema, 
dilated  bronchi,  and  phthisis.  If  capillary  bronchitis  comes  on,  the 
greatly  diminished  aeration  of  the  blood  increases  the  passive  cerebral 
congestion,  and  becomes,  therefore,  a  cause  of  convulsions  in  children. 
The  cerebral  comj^lications  consist  in  convulsions  and  hydrocephalus, 
the  result,  chiefly,  of  the  mechanical  obstacles  in  the  course  of  the  cir- 
culation. The  fluid  is  poured  out  in  the  ventricles,  in  the  perivascular 
lymph-spaces,  and  in  the  subarachnoid  spaces,  and  the  brain  is  more  or 
less  compressed  and  anaemic.  Sometimes  a  vessel  yields  under  the  in- 
creased pressure  in  coughing,  and  cerebral  hsemorrhage  results.  These 
cerebral  states  are  accompanied  by  the  usual  signs  and  symptoms.  The 
duration  and  termination  of  a  complicated  case  will,  of  course,  be  de- 
termined by  the  character  of  the  complication.  The  usual  termination 
of  uncomplicated  cases  is  in  recovery,  but  there  are  exceptions  to  this 
statement.  In  young  and  feeble  subjects,  the  action  of  the  heart  may 
be  suspended  by  the  expiratory  effort  in  coughing,  or  exhaustion  may 
result  from  loss  of  sleep  and  uncontrollable  vomiting. 

Treatment. — Arising  from  the  action  of  a  morbific  principle,  whose 
nature  is  unknown,  obviously  no  cure  will  be  discovered  until  the 
nature  of  the  cause  is  ascertained.  The  treatment  must  therefore  be 
merely  symptomatic.  During  the  catarrhal  stage,  those  remedies  are 
employed  that  have  been  most  useful  in  ordinary  bronchial  catarrh 
(]^.  Syrup,  scillas  comp.  3  j,  tinct.  aconiti  rad.  -ni,  xvi,  tinct.  opii  deo- 
dor.  in,,  viij,  syrup,  tolu  3  vij,  aq.  lauro-cerasi  3  j.  M.  Sig.  A  teaspoon- 
ful  every  two,  three,  or  four  hours).  Other  formulae  may  be  found  un- 
der the  head  of  "bronchial  catarrh."  The  iodide  and  bromide  of  am- 
monium given  together  are  highly  beneficial  during  the  catarrhal  stage 
and  as  the  spasmodic  stage  is  about  to  develop.  Tincture  of  aconite- 
root,  tincture  of  belladonna,  deodorized  tincture  of  opium,  and  fluid 
extract  of  ipecacuanha,  in  suitable  proportions  according  to  age,  is  a 
most  serviceable  combination.  Tincture  of  lobelia  may  be  substituted 
for  ipecac  in  the  above  formula,  as  advised  by  Ringer,  who  regards  it 
as  highly  serviceable  in  whooping-cough.  If  the  child  is  old  enough,  a 
gargle  of  bromide  of  potassium  may  also  be  used  Avith  advantage  dur- 
ing this  stage.  As  the  spasmodic  stage  approaches,  the  antispasmodic 
remedies  come  into  use.  Probably  the  most  eflicient  of  them  all  is 
opium,  in  the  form  of  the  alkaloid  codeia,  which  can  be  employed  with 
proper  precautions,  even  in  the  case  of  infants.    A  slight  hypnotic  effect 


MUMPS.  771 

should  be  maintained  constantly,  if  we  would  obtain  the  best  results 
from  it.  The  bromides  have  an  undoubtedly  good  effect  in  moderating 
the  violence  of  the  spasmodic  attacks.  Of  these,  the  monobromide  of 
camphor  seems  on  the  whole  to  be  most  beneficial.  It  can  be  given  in 
an  emulsion  or  pill-form,  in  from  two  to  ten  grains,  every  four  hours. 
The  very  best  results,  and  often  an  immediate  arrest  of  the  disease, 
can  be  procured  by  full  doses  of  quinia.  Not  all  cases  are  affected 
so  favorably  ;  but  in  the  author's  experience  no  single  remedy  does  so 
much  good  in  this  disease.  Atropia  often  acts  most  favorably,  but  is 
uncertain.  It  may  be  given  from  j-^q^  of  a  grain  to  y^-g-  of  a  grain, 
according  to  age  ;  but,  as  the  effect  is  well  maintained,  not  more  than 
three  doses  a  day  are  proper.  The  cough  by  habit,  which  remains 
after  the  subsidence  of  the  paroxysms,  is  often  admirably  relieved  by 
dilute  hydrocyanic  acid.  This  is  also  a  useful  remedy  during  the  maxi- 
mum of  the  disease.  Excellent  results  have  been  obtained  from  the 
use  of  the  mineral  acids,  especially  nitric,  in  the  treatment  of  the  dis- 
ease during  its  various  stages.  The  acids  should  be  well  diluted,  and 
given  in  some  simple  sirup,  especially  as  large  doses  are  necessary. 
Other  antispasmodics,  which  have  been  used  with  less  or  more  advan- 
tage, are  asafoetida,  musk,  ether,  chloroform,  spirit  of  chloroform, 
valerian,  etc.  Some  of  the  so-called  mineral  tonics — copper,  zinc,  and 
lead — have  been  administered  with  alleged  success.  Of  these,  probably, 
the  best  results  have  been  obtained  from  acetate  of  lead,  which  is  ex- 
hibited in  from  one  fourth  of  a  grain  up  to  five  grains,  according  to  the 
age.  If  the  tubes  are  much  obstructed  by  mucus,  or  if  capillary  bron- 
chitis supervene,  emetics  may  become  imperatively  necessary.  The 
yellow  subsulphate  of  mercury,  alum,  apomorphia,  and  ipecac,  are 
the  emetics  best  suited  to  the  purpose.  Good  results  are  obtained  by 
the  inhalation  of  carbolic  spray  in  many  cases.  An  atomizer  may  be 
used  directly  to  deliver  the  spray  in  the  fauces,  or  indirectly  by  filling 
the  air  of  the  apartment.  A  one  per  cent,  solution  is  strong  enough 
for  this  purpose.  Like  other  neuroses,  whooping-cough  is  much  influ- 
enced by  psychical  impressions.  Change  of  air  and  scene  is  therefore 
highly  beneficial.  To  this  mental  impression  must  be  referred  the 
supposed  agency  of  the  ammoniacal  odors  of  gas-works,  and  of  such 
medicines  as  cochineal,  which  affect  the  raind  by  a  brilliant  color  or 
disagreeable  odor. 

PAROTIDITIS— MUMPS. 

Definition. — Mumps  is  a  specific  inflammation  of  the  parotid  gland, 
propagated  by  a  peculiar  miasm,  self -limited,  occurring  usually  as  an 
epidemic,  and  characterized  by  a  tendency  to  migrate  into  the  mamma 
or  testes. 

Causes. — Nothing  is  known  of  the  materies  morhi  which  give  rise 
to  this  disease,  except  their  effects.     In  from  five  to  twenty  days  after 


772  MIASMATIC   DISEASES. 

exposure  of  a  healthy  person  to  the  atmosphere  about  an  individual 
having  the  "  mumps,"  the  former  is  also  attacked.  It  occurs  most  fre- 
quently in  males,  but  also  attacks  females,  and  the  usual  age  is  from 
five  to  fifteen  ;  but,  during  the  war  of  the  rebellion,  large  numbers  of 
raw  recruits  were  affected,  whose  average  age  was  not  less  than  twenty. 
Like  other  diseases  of  the  same  class,  it  usually  occurs  but  once  in  the 
same  individual. 

Symptoms. — There  is  an  initial  or  prodromic  period,  which  may  be 
so  slight  as  to  escape  observation.  It  begins  with  chilliness,  general 
malaise,  sometimes  vomiting,  and  a  fever  comes  on  immediately,  with 
the  usual  signs  and  symptoms  of  that  state.  In  from  twelve  to  thirty- 
six  hours  an  acute  pain  is  felt  behind  the  angle  of  the  jaw,  and  pene- 
trates to  the  throat,  frequently  into  the  ear.  The  jaw  becomes  stiff, 
and  a  swelling  appears  immediately  under  the  ear  and  extends  for- 
ward and  upward,  forming  an  immense  protuberance  in  front  of  the 
ear  and  behind  and  beneath  the  angle  of  the  jaw.  To  the  touch, 
doughy  and  elastic,  it  does  not  pit,  and  is  very  sensitive.  It  is  usually 
confined  to  the  parotid  gland,  but  in  severe  cases,  as  seen  in  the  army, 
the  neighboring  glands  are  implicated,  and  an  enormous  swelling, 
reaching  as  low  as  the  sternum,  results.  In  the  ordinary  cases  the 
maximum  enlargement  is  reached  in  from  three  to  six  days,  remains 
stationary  for  one  or  two  days,  and  then  rapidly  subsides,  completing 
the  revolution  in  from  eight  to  twelve  days.  In  some  cases  the  swol- 
len part  becomes  intensely  red,  the  color  disappearing  on  pressure,  to 
return  immediately  after  the  pressure  is  removed,  and  the  epidermis 
desquamating  as  the  swelling  subsides.  In  consequence  of  the  swell- 
ing, which  often  extends  to  and  involves  the  neighboring  tonsil,  and 
the  pain  produced  by  all  movements  of  the  jaw,  there  is  much  diffi- 
culty in  mastication  and  deglutition.  When  sapid  substances,  espe- 
cially acids,  are  taken  into  the  mouth,  an  acute  pain  shoots  through  the 
cheek  into  the  swollen  gland  and  ear.  Speech  is  also  more  or  less 
painful  and  difficult,  and  the  voice  is  muffled  and  indistinct.  A  viscid 
saliva  continuously  flows  from  the  partly-open  mouth.  Often  only 
one  parotid  is  affected,  and  the  other  is  attacked  in  a  day  or  two,  but 
it  not  unfrequently  happens  that  several  years  elapse  before  the  second 
gland  is  infected.  A  so-called  metastasis  not  unfrequently  takes  place, 
of  which  the  author  has  seen  a  number  of  examples.  During  the 
existence  of  the  parotid  swelling,  the  corresponding  testicle  becomes 
painful  and  swollen,  and  often  a  slight  bruising  of  the  organ  invites 
the  disease.  Sometimes  the  swelling  abandons  the  parotid,  when  the 
testis  begins  to  enlarge.  This  seems  like  a  true  metastasis.  The  mam- 
ma, labia  majora,  and  the  uterus,  are  the  organs  in  the  female  to  which 
the  disease  is  "  translated  "  ;  but  such  an  accident  must  be  excessively 
rare.  In  some  instances  an  interval  of  several  hours  occurs  between 
the   disappearance  from  the  parotid  and   the  appearance  elsewhere, 


MUMPS.  773 

with  the  effect  to  produce  alarming  symptoms  of  depression,  anxiety, 
almost  of  collapse. 

Course,  Duration,  and  Termination. — The  course  of  the  disease  is 
much  affected  by  the  hygienic  surroundings  of  the  patient  and  by  the 
constitutional  state  of  those  attacked.  During  the  late  war,  the  cases 
of  mumps  were  accompanied  by  high  fever,  often  delirium,  and  by  great 
depression  of  the  vital  powers  ;  pneumonia  was  a  not  unfrequent  com- 
plication, and  those  who  recovered  had  a  tedious  convalescence,  the 
blood  being  much  impoverished  and  the  body  emaciated.  Under  or- 
dinary circumstances,  mumps  is  a  mild  disease,  which  always  termi- 
nates in  recovery,  its  duration  varying  from  four  to  ten  or  twelve 
days.  The  importance  of  mumps  is  to  be  regarded  from  another  point 
of  view.  In  some  persons,  the  subjects  of  a  dyscrasia,  the  morbid 
condition  is  awakened  from  its  dormant  state  by  an  attack  of  mumps. 
The  tubercular  diathesis  is  the  most  common  of  these.  Rarely  has  the 
gland  suppurated,  when  attacked  by  mumps,  but  suppuration  is  the 
usual  result  when  an  inflammation  of  the  parotid  occurs  in  the  course 
of  typhoid  fever.  Atrophy  is  said  to  have  taken  place,  but  this  must 
be  an  excessively  uncommon  event.  The  glands  to  which  translation 
has  occurred  usually  recover  in  a  few  days,  without  receiving  any  in- 
jury. The  author  has  seen  several  cases  in  which  the  testes  were 
injured — the  damage  consisting  not  in  atrophy,  but  in  an  epididymitis, 
with  occlusion  of  the  spermatic  duct. 

Diagnosis. — The  prevalence  of  an  epidemic,  the  occurrence  of  swell- 
ing in  the  jDarotid  gland  with  fever,  'and  the  subsidence  of  the  swelling 
and  fever  in  a  few  days,  are  clinical  features  which  readily  separate 
mumps  from  other  affections.  In  children  having  bad  teeth  there  may 
be  produced  a  swelling  of  the  parotid  and  submaxillary  glands,  but 
here  the  pain  and  swelling  about  the  tooth  will  explain  the  nature  of 
the  case.  Inflammation  and  suppuration  of  the  parotid  will  be  differ- 
entiated by  the  formation  of  pus  and  by  the  usual  symptoms  of  glan- 
dular inflammation. 

Treatment. — As  this  is  a  self -limited  disease  for  which  we  have  no 
remedy,  it  is  wisest  to  attempt  no  perturbating  treatment.  Relief  to 
the  pain  is  best  afforded  by  some  warm  applications,  and  by  the  inter- 
nal use  of  morphia  and  quinine.  A  mild  laxative  should  be  adminis- 
tered, and,  if  the  skin  is  hot  and  dry,  the  body  may  be  sponged  off 
with  cold  water,  and  some  tincture  of  aconite  administered.  Recent 
observations  have  apparently  demonstrated  that  pilocarpus  possesses 
a  peculiar  curative  power.  This  may  be  given  in  the  form  of  the  fluid 
extract,  or  of  the  alkaloid  pilocarpine,  and  is  well  worthy  of  further 
trials.  The  patient  should  be  kept  in-doors,  and  every  effort  made  to 
avoid  the  least  contusion  of  the  testes. 


774  MALARIAL   DISEASES. 


MALARIAL    DISEASES. 


INTERMITTENT  AND  REMITTENT  FEVERS. 

Definition. — Malarial  fevers  are  characterized  by  their  prevalence 
in  certain  regions  of  the  world  known  to  produce  the  poison,  tnalaria, 
by  their  periodicity,  and  by  the  regular  succession  of  the  cold,  hot, 
and  sweating  stage.  Various  designations  have  been  applied  to  these 
forms  of  fever,  such  zb  fever  and  ague,  chills,  bilious  fever,  bilious  re- 
mittent, etc. 

Causes. — The  great  etiological  factor  is  malaria.  The  telluric  and 
other  conditions  favorable  to  the  development  of  malaria  exist  largely 
in  this  country,  along  the  Atlantic  seaboard  as  far  north  as  Boston  ; 
in  all  that  great  interior  region  drained  by  the  Mississippi  and  its 
tributaries,  the  valley  of  the  Sacramento  on  the  Western  coast,  etc 
For  an  exhaustive  account,  the  reader  is  referred  to  the  recent  work  of 
Lombard,  or  to  Hirsch.*  The  presence  in  the  atmosphere  of  a  mor- 
bific principle,  which  is  developed  when  certain  atmospheric  and  tel- 
luric influences  exist,  is  now  almost  universally  admitted.  Although 
the  existence  of  such  a  principle  is  admitted,  the  attempts  to  isolate 
and  define  it  have  proved  abortive,  unless  the  recent  discovery  of 
Klebs  and  Tommasi-Crudeli  supply  the  missing  form.f  The  "  Bacil- 
lus Malarise,"  which  they  have  discovered  floating  in  the  atmosphere 
of  the  Pontine  marshes,  produces  paroxysms  of  intermittent  fever  in 
the  animals  subjected  to  its  action  by  inoculation.  If  this  discovery 
is  confirmed,  and  these  rod-like  bodies  are  proved  to  be  the  cause  of 
those  phenomena  which  we  call  malarial  fever,  it  will  prove  to  be  the 
first  and  most  important  step  toward  permanent  eradication  of  the  dis- 
ease. Malaria  is  also  called  "  marsh-miasm,"  because  of  the  abundance 
of  this  poison  about  marshes.  But  not  all  marshes  produce  malaria. 
The  "  Dismal  Swamp,"  for  example,  is  free  from  marsh-miasm,  although 
apparently  well  adapted  to  produce  it.  Its  exemption  is  supposed  to 
be  due  to  the  growth  of  the  cypress-tree.  Marshes,  or  moist  alluvium, 
subject  to  annual  overflow,  and  exposed  to  the  action  of  the  sun,  by 

*  For  an  account  of  the  great  interior  valley  of  this  continent,  see  the  monumental 
work  of  Dr.  Daniel  Drake  ("  A  Systematic  Treatise,  Historical,  Etiological,  and  Practical, 
of  the  Principal  Diseases  of  the  Interior  Valley  of  North  America,"  page  723),  for  the 
reasons  which  induce  him  to  accept  the  doctrine  of  the  cryptogamic  origin  of  malarial 
diseases. 

f  Klebs  und  Tommasi-Crudeli,  "Studien  iiber  die  Ursache  des  Wechselfiebers  und 
liber  die  Natur  der  Malaria,"  "  Archiv  fiir  esperimentelle  Pathologic  und  Pharmacologic," 
Bd.  xl,  s.  311. 


INTERMITTENT   FEVER.  775 

reason  of  evaporation  or  subsidence  of  the  water,  is  peculiarly  active 
in  the  production  of  the  poison.  Marshes  that  are  partly  brackish  are 
worse  than  those  entirely  fresh.  In  this  country  malaria  is  produced 
more  from  the  sandy  alluvium  of  the  river  valleys  subject  to  annual 
overflow  and  heated  by  the  summer's  sun.  The  alluvium  and  some 
very  sandy  soils  of  the  malarial  zone,  not  subject  to  overflow,  also  gen- 
erate malaria,  which  is  freed  by  turning  up  the  soil.  Cultivation  and 
drainage,  however,  ultimately  destroy  the  malaria-breeding  grounds, 
and  marshes,  drained  and  planted,  finally  cease  to  produce  the  miasm. 
The  malaria  zone  extends  northwardly  as  far  as  the  isothermal  line  of 
59°  to  59*8°  Fahr.,  or  to  63°  north  latitude.*  It  is  the  mean  annual 
summer  temperature,  however,  which  determines  the  northern  limits 
of  malaria,  and  this  pursues  an  irregular  line  which  may  be  at  some 
points  above,  at  others  below,  the  sixty-third  parallel.  One  important 
factor  is  elevation,  malaria  not  breeding  above  five  thousand  feet  above 
the  sea,  which  seems  to  be  the  maximum  limit.  The  apparent  excep- 
tions to  this  afforded  by  the  so-called  "  mountain  fever  "  of  Colorado 
will  be  alluded  to  hereafter.  The  period  of  the  year  during  which 
malaria  is  most  active  is  summer  and  fall — from  June  till  November — 
for  at  this  period  only  has  the  sun  sufficient  power.  During  the  sea- 
son of  its  greatest  intensity,  the  poison  may  be  carried  up  ravines  to  a 
considerable  elevation,  or  to  distant  points.  A  position  to  the  leeward 
of  an  infected  locality  is,  therefore,  particularly  dangerous.  That  ma- 
laria is  soluble  in  water  and  is  contained  in  the  surface-water  of  in- 
fected districts  seems  now  to  be  well  established.  The  author  found 
the  surface-water  of  Kansas  to  produce  malarial  fevers  and  cholera. 
Some  trees  possess  the  property  of  absorbing  and  fixing  in  their  own 
structures  noxious  principles  contained  in  the  soil.  The  common  sun- 
flower, planted  in  moist  lowlands,  will  render  the  air  salubrious.  ,  The 
eucalyptus-tree  has  changed  the  nature  of  the  malaria-breeding  por- 
tions of  Algiers,  and  is  accomplishing  the  same  sanitary  result  for  the 
Campagna  of  Rome.  The  air  is  filtered  of  its  disease-germs  by  pass- 
ing through  a  belt  of  woodland  ;  even  shrubbery  a  few  feet  high  serves 
the  same  purpose,  and  protects  those  living  to  the  leeward.  All  ages 
are  susceptible  to  malarial  poisoning  ;  and  all  races  are  equally  so? 
except  the  black.  Males  are  somewhat  more  liable,  probably  because 
they  are  more  exposed  to  the  causes.  Women  suffer  more  from  the 
masked  forms,  as  hemicrania,  supra-orbital  neuralgia,  etc.  All  causes 
depressing  the  vital  forces  favor  the  reception  of  the  poison  and  the 
outbreak  of  the  disease.  Especially  is  exposure  to  cold  and  dampness 
combined  apt  to  cause  an  attack.  Previous  attacks  increase  the  sus- 
ceptibility.    If  those  living  in  the  midst  of  a  malarious  influence  go 

*  The  forty-seventh  parallel  is  given  by  Drake  (inipra)  as  the  northern  limit  in  this 
country,  and  the  summer  temperature  of  60°  Fahr, 


776  MALARIAL   DISEASES. 

from  it  into  a  region  entirely  free  from  all  suspicion  of  the  infection, 
an  outbreak  of  the  fever  is  apt  to  occur.  When  malarial  infection  is 
established  in  the  system,  all  diseases  occurring  will  have  more  or  less 
of  the  periodical  character.  The  form  of  the  malarial  disease  occur- 
ring will  depend  on  the  condition  of  the  system,  and  on  the  intensity 
of  the  poison  itself. 

Pathological  Anatomy. — The  changes  caused  by  malarial  poisoning 
are  essentially  the  same,  except  degree,  in  a;ll  the  forms  in  which  the 
disease  manifests  itself,  and  two  organs  (the  liver  and  sj)leen)  are 
chiefly  concerned.  In  acute  cases,  the  spleen  is  much  enlarged,  splenic 
pulp  greatly  increased  in  relative  quantity,  and  sometimes  there  are 
infarctions.  Gangrene,  abscess,  and  rupture  of  the  spleen  are  acci- 
dents which  have  been  observed  in  some  cases  of  pernicious  fever.  In 
some  chronic  cases  the  spleen  undergoes  enormous  enlargement ;  its 
texture  is  tough  and  smooth  on  section,  and  it  has  a  grayish  slate  color 
This  change  consists  in  a  hyperplasia  of  the  trabeculse  with  hyper- 
trophy of  the  cajDSule,  but  in  some  cases  the  increased  size  of  the  organ 
is  due  to  amyloid  degeneration.  When  the  organ  attains  to  very  large 
dimensions,  it  is  known  as  "ague-cake."  Usually,  in  chronic  malarial 
poisoning,  the  sj^leen  is  somewhat  enlarged,  but  not  so  much  increased 
as  to  be  called  ague-cake,  the  change  consisting  in  a  diminution  of  the 
splenic  pulp  and  an  hypertrophy  of  the  trabeculse  and  capsule.  The 
color  of  the  spleen  is  grayish  or  slate,  due  to  pigment  deposits,  which 
ai-e  found  in  greatest  abundance  in  the  walls  of  the  blood-vessels, 
where  it  is  deposited  by  disintegration  of  the  red  globules.  Important 
changes  take  place  in  the  liver.  During  an  intermittent  the  liver  be- 
comes hyperaemic  and  swollen,  and,  if  jaundice  is  present,  very  much 
enlarged,  stained  with  pigment,  and  the  portal  capillaries  distended 
with  blood,  and  the  gall-bladder  filled  with  thick,  tarry,  dark-brown 
bile.  In  chronic  cases  the  liver  has  a  grayish  tint,  due  to  pigment  de- 
posits along  the  vessels  ;  it  is  firm  in  texture,  and  the  divided  parts 
preserve  sharp  outlines  ;  the  hepatic  cells  are  pale  and  filled  with  fat- 
granules.  The  intestinal  canal  also  presents  characteristic  changes. 
During  an  acute  attack  there  are  extensive  and  considerable  hyper- 
aemia  of  the  mucous  membrane  and  more  or  less  thickening  and  eleva- 
tion of  the  solitary  and  agminated  glands.  In  the  chronic  cases  the 
intestinal  mucous  membrane  has  a  general  slate-colored  hue,  due  to  pig- 
mentation of  the  capillaries.  The  glands,  solitary  and  agminated,  are 
thickened  and  enlarged  from  accumulation  of  their  contents  and  hyper- 
semia,  and  thickly  disseminated  through  the  groups  of.  Peyer  are  the 
black  orifices  of  the  follicles  of  Lieberkuhn.  The  kidneys  are  also 
affected  by  characteristic  changes  :  hyperasraia  during  the  acute  attack, 
and  subsequent  alterations,  as  thickening  of  the  basement  membrane, 
the  tubules  filled  with  cast-off  epithelium,  the  interstitial  connective 
tissue  proliferating,  and  more  or  less  amyloid  change  in  the  Malpighian 


INTERMITTENT   FEVER.  YYY 

tufts  and  small  arteries.*  The  brain  and  spinal  cord  do  not  escape. 
In  ordinary  cases  during  an  acute  attack,  there  is  more  or  less  hyper- 
femia  of  the  brain  ;  in  pernicious  remittent,  capillary  pigment  embo- 
lisms and  minute  extravasations  occur  ;  but  more  usually  the  condition 
is  that  of  hypersemia  and  oedema  of  the  membranes  and  of  the  cerebral 
matter.  In  the  lungs  there  may  be  infarctions,  croupous  pneumonia, 
etc.  The  heart  is  flabby,  its  muscular  fiber  easily  toi-n,  the  right  cavi- 
ties distended  with  soft,  black  coagula,  very  loose.  The  changes  in 
the  blood  have  not  been  studied  with  accuracy.  Bence  Jones's  dis- 
covery of  a  fluorescent  substance  in  the  blood  and  tissues  has  not 
thrown  any  light  on  the  question,  since  this  substance  or  rather  reaction 
is  very  widely  distributed  and  is  without  importance.  It  is  true.  Pepper 
and  Rhoads  found  this  substance  diminished  by  malarial  fever,  but 
nothing  has  resulted  from  these  observations.  The  white  corpuscles 
are  much  increased  in  numbers  relatively,  but  the  most  important 
change  in  the  composition  of  the  blood  is  the  formation  of  pigment 
from  the  haemoglobulin,  the  hoematin  is  set  free,  and  is  found  in  all  the 
principal  organs  associated  with  the  vessel-walls,  and  rarely  collected 
in  masses,  and  forming  capillary  embolisms. 

Symptoms. — Prodromal  Stage. — A  certain  period  elapses  after  ex- 
posure before  there  is  any  disturbance  in  the  functions.  This  period 
of  incubation  varies  from  a  few  hours  to  many  weeks,  the  variations 
being  due  to  the  intensity  of  the  poison  and  the  susceptibility  of  the 
individual.  The  average  which  is  most  usual  is  fourteen  days.  In  a 
large  proportion  of  cases  there  are  symptoms  indicating  that  the  infec- 
tion is  working.  These  are  called  prodromes.  The  patient  has  a  feel- 
ing of  lassitude  and  weariness  ;  he  suffers  with  backache  and  general 
muscular  soreness  ;  he  has  an  irresistible  inclination  to  yawn  and 
stretch,  especially  in  the  early  morning,  and  on  cold,  damp  days  ;  his 
head  aches,  tongue  is  coated,  stomach  is  squeamish  ;  toward  evening 
his  skin  becomes  warm  and  dry,  his  sleep  is  disturbed  by  dreams,  and 
in  the  early  morning  a  profuse  sweat  occurs.  In  other  cases  the  pro- 
dromes consist  merely  in  a  coated  tongue,  yellow  sclerotic,  and  a  gen- 
eral yellowish  hue  of  the  skin,  languor,  loss  of  appetite,  and  constipa- 
tion ;  the  urine  is  loaded  with  bile-pigment,  and  deposits  an  abundance 
of  urates.  Gradually  thus  may  the  patient  drift  into  a  paroxysm  of 
fever,  without  there  being  any  distinct  initial  symptom — the  fonn 
assumed  developing  by  a  process  of  selection,  as  it  were,  out  of  the 
materia]  offered.  Or  the  disease  may  begin  abruptly  in  the  midst  of 
apparently  full  health,  or  during  the  puerperal  state,  or  in  the  course 
of  chronic  malarial  poisoning. 

Intermittent  Fever. — Ague  and  Fever. — There  are  three  distinct 

*  The  author  gives  the  results  of  numerous  observations  and  studies  made  during  his 
service  in  the  regular  army,  from  185Y  to  1864.  (See  his. contributions  to  United  States 
"Sanitary  Commission  Memoirs,"  medical  volume.) 


<  i 


g  MALAEIAL  DISEASES. 


events  in  every  paroxysm  of  intemaittent  fever  :  the  chill,  the  fever, 
and  the  sweat.  When  the  chill  comes  on,  there  is  a  feeling  of  wretched- 
ness, of  weariness,  and  illness.  There  occur  headache,  backache,  and 
soreness  in  the  muscles  of  the  extremities.  Creeping  chills  are  felt 
alon^  the  hack,  there  are  gaping  and  precordial  oppression,  the  whole 
surface  grows  cold,  and,  feeling  extremely  weary  and  depressed,  the 
patient  gladly  betakes  himself  to  bed  ;  but  the  coldness  intensifies,  no 
matter  how  much  covering  is  piled  on  ;  the  fingers  become  blue,  the 
lips  blue,  the  nose  pinched,  the  countenance  shrunken,  and  the  chilli- 
ness is  now  aggravated  into  shuddering.  One  fit  after  another  of 
shuddering  comes  on  ;  the  teeth  rattle  together ;  the  bed  shakes. 
Meanwhile  the  pains  in  the  head  and  back  and  limbs  continue  ;  there 
is  extreme  thirst,  and  often  nausea  and  vomiting  ;  respiration  is  quick 
and  sighing,  the  voice  is  weak  and  tremulous  ;  the  pulse  is  small,  rapid, 
and  the  tension  high  ;  the  urine  is  pale,  watery,  and  increased  in  quan- 
tity. Notwithstanding  the  overpowering  sense  of  coldness,  it  is  found 
to  be  objective,  for  the  temperature  begins  to  rise  with  the  onset  of 
the  chill,  the  thermometer  indicating  fever  whether  in  the  axilla,  mouth, 
or  rectum.  The  duration  of  the  chill  varies  from  a  mere  instantaneous 
chilliness  to  several  hours  of  shaking,  the  usual  length  of  the  ague 
being  a  quarter  to  a  half  hour.  The  chill  does  not  terminate  abrupt- 
ly. The  shaking  subsides  slowly,  as  a  feeling  of  warmth  gradually 
diffuses  outwardly,  or  flashes  occasionally  through  the  limbs.  After  a 
time  the  body  feels  hot,  the  extremities  grow  warm,  the  pulse  becomes 
fuller  and  stronger,  the  blueness  of  the  skin  is  replaced  by  a  red  blush, 
the  face  is  full  instead  of  retracted,  flushed  instead  of  pallid.  The 
pains  in  the  back  and  limbs  disappear,  but  the  headache  rather  in — 
creases,  and  throbbing  is  felt  in  the  temples,  and  with  each  pulsation 
of  the  carotid.  The  pulse  grows  full,  rapid,  and  strong;  respiration 
is  more  frequent  and  easy.  The  head  becomes  hot,  feels  full  ;  there 
are  noises  in  the  ears  ;  vertigo  and  nausea  are  experienced  on  the  at- 
tempt to  get  up  ;  the  ideas  are  confused,  and  the  mind  is  dull,  and 
there  may  be  excitement  and  delirium.  The  usual  symptoms  attend 
this  feverish  stat-e — there  are  thirst,  a  dry  mouth,  constipation,  high- 
colored,  scanty,  and  acid  urine.  The  duration  of  this  stage  varies  from 
an  hour  or  two  to  ten  or  twelve,  and  it  is  succeeded  by  the  third  or 
sweating  stage.  While  the  fever  is  raging,  a  gentle  moisture  appears 
on  the  forehead  and  face,  and  more  abundantly  in  the  axilla,  groin, 
between  the  thighs,  and  then  on  the  skin.  Presently  the  moisture 
increases  to  drops,  and  finally  pours  off,  wetting  the  shirt  and  the 
sheets.  As  the  sweating  progresses,  the  fever  declines,  the  pulse  be- 
comes softer  and  its  tension  is  lowered  ;  the  headache  and  other  pains 
and  the  general  muscular  soreness  cease  ;  the  mouth  gets  moist  and 
the  thirst  lessens  ;  the  respiration  becomes  easy  and  regular,  and  the 
patient,  although  exhausted,  experiences  a  feeling  of  comfort  and  well- 


INTERMITTENT  FEVER.  779 

being,  and  often  falls  asleep.  The  sweat  is  acid  in  reaction,  is  rich  in 
salts,  and  contains  a  large  quantity  of  organic  matter  with  fat  acids, 
to  which  its  animal  odor  is  chiefly  due.  The  urine  also  is  acid,  has  a 
high  color  owing  to.  a  quantity  of  pigment,  and  contains  much  uric 
acid  and  urates,  which  are  deposited  abundantly  on  cooling.  The 
amount  of  urea  discharged  corresponds  closely  with  the  range  of  tem- 
perature, and,  as  soon  as  the  fit  of  ague  begins,  the  production  of  urea 
increases  (Ringer).  A  sudden  decline  in  the  amount  of  urea  takes 
place  during  the  sweating  stage,  and  in  the  apyretic  interval  it  is 
below  the  normal.*  The  excretion  of  chloride  of  sodium  also  is 
always  increased  greatly  during  the  cold  and  hot  stage  of  an  ague 
paroxysm.  These  facts  indicate  that  the  increased  temperature  of  the 
febrile  movement  represents  the  consxunption  of  tissue.  TVhen  the 
paroxysm  is  entirely  ended  by  the  completion  of  the  sweating  stage, 
in  about  twelve  hours,  on  the  average,  from  the  beginning  of  the  seiz- 
ure, the  patient  presents  evidences  of  the  revolution  through  which  he 
has  passed.  There  is  experienced  a  sense  of  exhaustion,  and  the  func- 
tions generally  are  depressed  ;  the  tongue  coated,  the  ajypetite  poor, 
the  epigastrium  and  hypochondriac  regions  more  or  less  uneasy  and 
sensitive  to  pressure,  and  the  skin  is  slightly  or  considerably  jaundiced. 
Not  every  ague  attack  is  so  severe,  and  great  variations  are  observed 
as  regards  the  several  stages.  Thus  the  chill  may  be  a  mere  creeping 
or  crawling  sense  of  coolness  along  the  spine,  while  the  fever  and 
sweat  may  be  extremely  severe.  Again,  the  chill  may  be  pronounced 
and  the  fever  and  sweat  trivial ;  or  there  may  be  profuse  sweating  at 
regular  intervals,  without  any  but  the  most  trivial  and  transient  dis- 
turbances in  other  respects. 

Course,  Duration,  and  Termination, — After  a  certain  interval,  which 
is  different  in  the  several  types  of  fever,  the  paroxysm  recurs,  and 
there  are  again  presented  the  phenomena  of  chill,  fever,  and  sweat.  In- 
termittent fever  follows  a  definite  law  of  periodicity.  Sometimes  the 
paroxysms  occur  daily,  coming  on  at  a  special  time  with  nearly  uni- 
form particularity.  This  variety  or  type  is  known  as  qxiotidian  inter- 
tnitteyxt.  Again,  the  paroxysms  occur  on  alternate  days — on  the  third 
day,  including  the  days  of  attack — and  are  hence  known  as  tertian  in- 
termittent. In  the  temperate  malarious  regions  the  tertian  form  is 
the  most  frequent.  There  is  still  a  third  variety,  in  which  the  parox- 
ysms occur  on  the  fourth  day,  including  the  days  of  illness,  and  hence 
is  known  as  quartan  intermittent.  This  last  variety  is  uncommon. 
Sometimes  two  distinct  paroxysms  occur  on  the  same  day,  and  hence 
we  have  double  quotidian,  double  tertian,  etc.  The  author  has  en- 
countered two  cases  of  double  quotidian  in  the  puerperal  state.    Other 

*  Dr.  Joseph  Jones,  "  Trans.  Amer,  Med.  Association,"  1859,  vol.  xii,  p.  507 ;  Sydney 
Ringer,  "  Medico-Chirarg.  Trans.,"  second  series,  1859,  vol.  xsit,  p.  361;  Dr.  Parke3, 
"  On  the  Composition  of  the  Urine  in  Health  and  in  Disease,"  London,  1860,  p.  235. 


780  MALARIAL   DISEASES. 

eccentricities  have  been  observed.  Thus,  a  quotidian  may  have  on 
alternate  days  corresponding  paroxysms  as  to  time  and  character,  and 
may  consist  of  two  tertians.  Such  a  variation  is  sometimes  called  a 
double  tertian.  The  tri2yle  tertian  is  a  variety  in  which  there  are  two 
distinct  paroxysms  on  one  day  and  one  paroxysm  on  the  next ;  the 
duplicated  tertian  has  two  paroxysms  on  alternate  days  ;  and,  finally, 
the  double  quartan  has  a  paroxysm  on  one  day,  a  milder  one  the  next 
day,  and  a  day  without  fever.  The  duration  of  a  paroxysm  of  fever 
varies  with  the  type  :  the  quotidian  lasts  from  eight  to  twelve  hours, 
the  tertian  from  six  to  eight,  and  the  quartan  from  four  to  six.  The 
paroxysms  do  not  always  occur  at  the  same  hour  ;  if  uninterf ered  with 
they  anticipate,  the  second  occurring  a  little  earlier  than  the  first,  and 
the  third  earlier  than  the  second.  On  the  other  hand,  as  the  force  of 
the  attack  is  declining,  the  paroxysms  are  postponed.  The  quotidian 
usually  begin  in  the  early  morning,  the  tertian  toward  or  at  noon  ; 
if  not  interfered  with  by  treatment,  an  intermittent  will  ultimately 
terminate  spontaneously,  but  the  period  at  which  this  result  will  be 
reached  depends  on  the  climate,  constitution,  season,  degree,  in  which 
the  system  has  been  poisoned  by  malaria,  etc.  Very  mild  quotidians 
may  terminate  in  a  month,  tertians  in  two  months  or  longer,  and 
quartans  many  months.  When  malarial  poisoning  has  thoroughly  oc- 
curred, the  disposition  to  attacks  continues  for  a  long  period — often 
for  years.  Exposure  to  cold,  errors  of  diet,  fatigue,  mental  anxiety — 
a  variety  of  causes,  of  sufficient  force  to  disturb  the  functions — may 
excite  a  new  attack.  Very  often  a  change  of  type  ensues  :  the  quo- 
tidian may  become  a  tertian,  or  the  gravity  of  the  case  is  increased — a 
remittent  succeeding  to  an  intermittent  fever.  It  is  rare  for  an  inter- 
mittent fever  to  terminate  in  death  directly,  but  indirectly,  through 
the  various  alterations  occurring  in  malarial  poisoning,  a  large  mortal- 
ity results.  The  course  of  intermittent  is  much  diversified  by  the  va- 
riations from  the  typical  form  known  as  masked  intermittent.  When 
an  attack  has  been  interrupted  by  the  exhibition  of  the  usual  remedies, 
there  may  occur  at  the  regular  periods  subsequently  a  mere  temporary 
rise  of  temperature,  a  profuse  sweat,  a  copious  urinary  discharge,  an 
attack  of  diarrhoea,  etc.  With  or  without  any  previous  manifestation 
of  fever,  those  affected  with  malaria  may  suffer  with  various  substitu- 
tion diseases,  as  intermittent  hgematuria,  pulmonary  haemorrhage,  bron- 
chitis, coryza,  iritis,  jaundice,  diarrhoea  or  dysentery,  vomiting,  urtica- 
ria, roseola,  and  numerous  other  maladies.  These  substitution  diseases 
agree  in  coming  on  at  a  fixed  hour  or  nearly  so,  in  disappearing  after 
a  time  without  any  apparent  reason,  in  coming  on  again  at  the  ap- 
pointed time  or  anticipating  a  little,  and  in  yielding  promptly  to  the 
anti-periodic  while  obstinately  resisting  other  means  of  treatment 
Probably  the  most  common  of  these  substitution  diseases  is  neuralgia 
and  the  most  usual  position  of  this,  the  ophthalmic  division  of  the 


'  INTERMITTENT   FEVER.  Y81 

fifth  ;  but  it  may  occur  in  the  other  divisions  of  this  nerve — in  the  oc- 
cipital nerve,  in  the  sciatic,  and  elsewhere.  In  what  position  soever 
the  neuralgia  appears,  the  attacks  are  periodical,  and  usually  quotidian. 
When  it  occurs  in  the  ophthalmic  division,  there  are  intense  pain 
in  the  region  of  the  eye  and  forehead  and  throbbing  temples,  the  con- 
junctiva is  injected,  and  the  eyelids  are  swollen  ;  general  malaise,  nau- 
sea and  vomiting,  some  chilliness,  elevation  of  temperature,  and  sweat- 
ing are  the  systemic  symptoms,  which  associate  these  cases  with  the 
ordinary  intermittents.  When  sciatica  occurs  it  may  assume  the  in- 
termittent or  remittent  form,  is  on  the  right  side  in  the  majority,  and 
is  sometimes  accompanied  by  clonic  spasms.  Not  frequently,  attacks 
occur  in  the  cardiac  nerves,  producing  the  phenomena  of  angina  pec- 
toris, viz.,  precordial  oppression  and  pain,  a  sense  of  impending 
death,  great  difficulty  of  breathing,  a  slow,  hard  pulse,  cold  skin, 
blue  lips  and  fingers,  ending  with  free  eructations  of  gas,  the  dis- 
charge of  a  quantity  of  pale,  watery  urine,  etc.  Various  nervous  dis- 
eases, as  delirium,  puerperal  mania,  hallucinations,  coma  vigil,  etc., 
have  occurred,  as  those  above  mentioned,  in  substitution  of  malarial 
attacks.  Besides  the  intermissions,  the  regularity  in  the  periods  of 
recurrence,  and  the  promptness  with  which  they  yield  to  quinine, 
these  substitution  maladies  may  be  accompanied  by  some  of  the  other 
objective  phenomena  of  malarial  fever. 

Pernicious  Intermittent. — In  those  parts  of  the  United  States 
where  the  malaria  is  most  concentrated  and  the  malarial  fevers  most 
severe,  the  ordinary  intermittent  may  assume  a  most  formidable  char- 
acter, termed  pernicious  in  scientific  works,  and  popularly  known  as 
congestive.  That  an  attack  of  intermittent  will  assume  a  pernicious 
character  is  not  announced  in  advance.  Sometimes  the  condition  of 
exhaustion  induced  by  a  severe  attack  of  cholera  morbus  may  invite  a 
paroxysm  which  assumes  the  pernicious  character,  or  the  state  of  the 
patient  may  be  rendered  unfavorable  by  some  other  malady,  or  there 
may  be  present  some  symptoms  of  cerebral  disturbance,  but  in  general 
there  is  nothing  to  indicate  the  approach  of  the  severe  type.  Usually, 
the  case  has  the  ordinary  aspect  of  an  intermittent  for  the  first,  second, 
and  third  paroxysm.  There  may  be  a  gradual  increase  in  the  severity 
of  each  attack,  or  the  usual  type  may  be  followed  by  a  pernicious  one. 
It  is  not  often  that  the  first  pernicious  attack  proves  fatal,  but  a  repe- 
tition of  them  becomes  more  and  more  dangerous,  and  after  the  first 
any  succeeding  attack  may  be  fatal.  The  pernicious  attacks  assume 
several  forms — the  algid,  choleriform,  diaphoretic,  the  pneumonic,  the 
nephritic,  and  the  cerebro-spinal.*  In  the  cdgicl  form  the  depression  of 
the  heart,  which  is  its  distinctive  feature,  comes  on  either  in  the  fever 
or  sweating  stage.     While  intense  internal  heat  is  experienced  by  the 

*  Jaccoud,  op.  cit.,  p.  605. 


782  MALARIAL   DISEASES. 

patient,  the  surface  becomes  cold,  livid,  and  cyanosed,  the  pulse  small 
and  exceedingly  rapid,  the  action  of  the  heart  feeble  ;  the  skin  is  cov- 
ered with  a  cold,  sticky  sweat,  but  the  mind  is  undisturbed.  If  death 
occurs,  the  condition  of  coldness  and  dejDression  increases,  but  if  recov- 
ery, after  a  longer  or  shorter  duration  of  the  algid  state,  the  action  of 
the  heart  grows  a  little  stronger,  and  gradually  warmth  is  restored  to 
the  surface.  In  the  choleraic  variety  of  pernicious  fever  there  is  pro- 
duced an  algid  state  resembling  that  of  cholera,  by  an  uncontrollable 
vomiting  and  purging,  and  the  resemblance  is  carried  to  the  stage  of 
reaction  ;  for  if  the  patient  emerge  from  the  condition  of  collapse  he 
experiences  the  fever  of  reaction — the  typhoid  state — which  occurs 
under  similar  circumstances  in  cholera.  In  the  sweating  or  diaphoretic 
variety  of  pernicious  intermittent  no  notable  change  in  the  demeanor 
of  the  case  takes  place  until  the  stage  of  sweating  arrives,  when,  not 
only  does  an  enormous  transpiration  occur  through  the  skin,  but  the 
temperature  falls  below  the  normal,  the  circulation  becomes  exceed- 
ingly depressed,  the  surface  cold  and  cyanosed  ;  the  urinary  secretion 
is  greatly  diminished  or  totally  suppressed,  and  in  many  cases  there  are 
passed  large,  whitish  stools,  without  bile.  Under  such  circumstances 
there  may  be  more  or  less  jaundice,  and  by  many  authors  those  cases 
characterized  by  a  marked  biliary  derangement  are  erected  into  a  dis- 
tinct class,  as  pernicious  icteric  (Jaccoud).  When  the  vaso-motor  dis- 
turbance, which  underlies  the  forms  of  pernicious  intermittent,  already 
described,  is  precipitated  on  some  internal  organ,  there  will  ensue,  in 
addition  to  the  condition  of  coldness,  cyanosis,  and  feeble  circulation, 
the  symptoms  of  some  particular  internal  malady^ — pneumonia  or  pleu- 
risy, for  example.  A  malarial  pneumonia  pursuing  the  ordinary  course, 
the  symptoms  remitting  in  accordance  with  the  type  of  the  malarial 
fever,  will,  if  the  pernicious  symptoms  set  in,  assume,  in  a  short  time, 
a  condition  of  extreme  danger,  owing  to  the  disturbance  in  the  pulmo- 
nary circulation.  When  the  vaso-motor  derangement  affects  the  kid- 
neys during  the  course  of  pernicious  intermittent,  there  is  produced  the 
nephritic  form  of  pernicious  fever,  and  the  signs  are  hasmaturia,  al- 
buminuria, or  suppression  of  urine.  The  most  common  form  of  perni- 
cious intermittent  is  that  affecting  the  nervous  centers.  There  are 
usually  some  preliminary  symptoms,  as  headache,  vertigo,  and  a  sopo- 
rose state,  which  are  present  during  the  first  paroxysms,  or  in  the  in- 
terval preceding  the  pernicious  attack.  During  the  fever  stage  the 
patient  falls  into  a  profound  coma,  and  this  is  all  the  more  dangerous, 
because  it  may  resemble  natural  sleep.  In  the  first  attack,  the  patient 
usually  rallies  during  the  sweating  stage,  in  twelve  to  twenty-four 
hours,  or  the  coma  may  simply  deepen,  the  heart  become  more  and 
more  depressed  until  death.  The  succeeding  attacks  are  usually  fatal. 
This  comatose  form  may  assume  an  appearance  of  apparent  death,  the 
patient  being  in  a  cataleptic  condition,  or  it  may  be  preceded  by  faint- 


INTERMITTENT  FEVER.  783 

ing-fits,  a  state  of  genuine  coma  then  coming  on.  In  still  other  cases 
this  cerebral  form  of  pernicious  fever  may  assume  the  appearance  of 
maniacal  delirium,  or  it  may  ajffect  the  brain  and  cord  simultaneously, 
causing  tonic  and  clonic  spasms,  etc.  In  this  country  the  most  fre- 
quent varieties  of  pernicious  intermittent  are  the  algid,  the  choleraic, 
the  pneumonic,  and  the  comatose. 

SequelaB  of  Intermitteilt  Fever. — When  attacks  of  intermittent  fever 
have  been  interrupted  by  appropriate  treatment,  relapses  are  apt  to 
occur.  In  fact,  by  the  treatment  only  the  objective  phenomena  of 
fever  may  have  been  removed,  and  consequently  but  a  certain  time  will 
be  required  to  develop  new  paroxysms.  In  cases  thus  temporarily 
suspended  and  apparently  well,  it  will  be  found  on  close  inspection 
that  there  ai*e  still  occurring  in  regular  sequence  certain  disturbances. 
The  thermometer  may  show  some  slight  elevation  of  temperature; 
there  may  be  a  distinct  sweat,  or  a  profuse  urinary  discharge  may  occur, 
and,  after  a  period  determined  by  the  type,  the  paroxysms  will  recur. 
These  relapses  are  said  to  appear  on  the  seventh,  fourteenth,  and  twen- 
ty-first days,  but  it  is  more  correct  to  state  that  the  periods  of  recur- 
rence are  multiples  of  the  first  or  former  attacks.  If,  for  example,  the 
case  is  tertian,  the  first  relapse  would  occur  on  the  sixth  day  ;  if  quo- 
tidian, relapses  would  take  place  on  the  third,  sixth,  ninth,  and  twelfth 
days  ;  and  thus  on.  Not  only  the  regular  cases,  but  the  various  masked 
and  pernicious  forms,  manifest  the  same  tendency  and  pursue  the  same 
laws  as  regards  the  relapses.  The  tendency  to  the  occurrence  of  re- 
lapses is  much  affected  by  age — is  much  greater  under  twenty,  and 
declines  rapidly  after  twenty.  The  time  at  which  they  occur  varies 
greatly,  from  one  week  to  six  months,  but  the  probability  of  a  relapse 
is  very  slight  after  six  weeks  have  passed.  The  type  of  the  disease 
frequently  changes  in  undergoing  a  relapse,  the  tendency  being  to 
more  frequent  attacks,  the  tertians  becoming  quotidian.  The  ten- 
dency to  relapses  is  due  to  the  persistence  of  the  conditions  which  de- 
termined the  first  seizure.  The  result  of  the  long-continued  action  of 
malaria  is  most  disastrous.  The  blood  loses  its  red  globules,  while  the 
w'hite  diminish  in  size  and  increase  in  number  ;  the  ankles  become 
oedematous  ;  the  liver  and  spleen  enlarge  ;  the  skin  is  yellow,  earthy,  or 
jaundiced  ;  the  body  emaciates  ;  the  appetite  is  poor,  the  digestion 
feeble,  the  stools  clay-colored,  and  the  urine  may  contain  albumen,  and 
is  deeply  colored  with  bile-pigment  ;  fluid  accumulates  in  the  peri- 
toneal cavity,  etc.  Palpitation  of  the  heart  and  a  venous  hum  over  the 
course  of  the  great  vessels  occur  because  of  the  watery  state  of  the 
blood,  and  for  the  same  reason  epistaxis  takes  place  and  the  menses 
become  profuse.  The  changes  which  affect  the  composition  of  the 
blood  are  due  to  various  causes — to  the  interference  by  stomach  and 
intestinal  troubles  with  the  primary  assimilation,  to  the  morbid  state 
of  the  blood-making  organs,  especially  to  the  destruction  in  the  spleen 


^84  MALARIAL   DISEASES. 

of  the  red-blood  globules,  and  to  the  conversion  of  haematin  into  pig- 
ment, which  we  have  shown  to  take  place  at  various  points.  An  impor- 
tant fact  is  the  accumulation  of  this  pigment,  and  its  almost  universal 
distribution  throughout  the  body.  The  mischief  done  by  pigment  em- 
bolisms is  doubtless  very  great.  Besides  those  changes  belonging  to 
chronic  malarial  intoxication  and  the  sequelae  above  mentioned,  there 
are  various  maladies  of  high  importance,  which  may  have  their  origin 
in  the  malarial  cachexia.  Among  these  are  nephritis,  amyloid  degen- 
eration of  the  liver,  kidneys,  spleen,  and  intestinal  glands  ;  sclerosis  of 
the  liver,  anaemia,  dropsy,  tuberculosis,  neuralgia,  epilepsy,  hemiplegia, 
mania  with  suicidal  tendency,  etc. 

Diagnosis. — A  case  of  intermittent,  complete  at  all  points,  could 
hardly  be  confounded  with  any  other  malady.  It  may  be  mistaken 
for  pyaemia,  in  which  there  are  chills,  fever,  and  sweats,  with  an 
apyretic  interval.  It  differs,  however,  from  pyaemia  in  its  origin,  and 
in  the  clinical  course  ;  intermittent  is  due  to  a  supposed  miasm — pyse- 
mia  to  wounds,  suppuration  of  veins,  etc,  ;  intermittent  is  regular  in 
its  course — pyaemia  is  very  irregular,  no  defined  intervals  occurring  ; 
intermittent  is  a  benign  affection,  promptly  cured  by  quinia — pyaemia 
is  a  fatal  disease,  over  which  quinia  has  no  influence.  Masked  inter- 
mittents  are  differentiated  from  the  local  maladies  whose  form  they 
assume,  by  the  fact  that  malaria  is  abundant,  that  these  diseases  are 
distinctly  periodical,  and  that  they  yield  to  the  remedies  for  malarial 
diseases.  The  diagnosis  of  the  various  pernicious  forms  is  very  dif- 
ficult. It  ought  to  be  remembered  that  the  pernicious  attack  has 
occurred  at  a  time  when  the  regular  paroxysm  is  due,  and  that  prob- 
ably a  strong  malarial  influence  prevails.  The  comatose  variety  is 
often  preceded  by  symptoms  indicative  of  the  disturbance  in  the  intra- 
cranial circulation,  such  as  headache,  vertigo,  sopor,  etc. 

Remittent  Fever.— The  remittent  fever  of  this  country  is  known  as 
hilioiis  fever  and  bilious  remittent  fever.  The  designation  bilious  has 
been  applied  because  of  the  prominence  of  the  symptoms  referable  to 
the  hepatic  function.  Every  summer  and  fall  this  disease  prevails 
largely  through  the  South  and  West.  The  author  saw  in  Kansas,  in 
1857,  at  the  military  post  of  Fort  Leavenworth,  a  great  many  examples 
of  the  severe  form  of  remittent  fever  prevalent  in  that  locality.  The 
cases  of  remittent  are  divisible  into  three  groups — mild,  severe,  and 
grave.  These  divisions,  generally  recognized  by  systematic  writers, 
are  based  on  clinical  experience.  In  the  mildest  form  the  fever  con- 
tinues for  four  or  five  days,  when  distinct  intermissions  occur  ;  the 
remissions  are  well  defined  from  the  beginning,  and  increase  day  by 
day  into  the  complete  intermission.  Usually  an  attack  of  remittent 
fever  is  preceded  or  accompanied  by  a  coated  tongue,  yellow  and 
thick  ;  a  heavy,  offensive  breath  ;  nausea  and  vomiting — the  matters 
ejected  consisting,  for  the  most  part,  of  acid  mucus  and  bile  ;  violent 


REMITTENT   FEVER.  785 

headache,  especially  of  the  frontal  region,  ringing  in  the  ears,  throb- 
bing temples,  and  a  chill  of  moderate  severity,  which  marks  the  real 
onset  of  the  disease.  The  remission  is  every  day  (quotidian  type),  or 
on  alternate  days  (tertian  type),  and  is  marked  by  a  distinct  sweat, 
which  coincides  with  the  decline  of  temperature.  More  or  less  chilli- 
ness, sometimes  a  well-defined  chill,  begins  the  ncAv  paroxysm.  Rest- 
lessness and  wakefulness  at  night,  bleeding  at  the  nose,  a  slight  bron- 
chitis, and  an  eruption  of  herpes,  are  also  symptoms  of  this  form.  In 
the  severe  form  the  fever  is  less  broken  by  remissions,  and  assumes  a 
type  approaching  the  continued.  About  the  third  day  there  are  be- 
ginning symptoms  of  cerebral  derangement,  as  stupor  and  delirium  ; 
the  tongue  is  dry  and  cracked  ;  the  spleen  and  liver  are  enlarged  and 
swollen  ;  a  well-marked  icterus  stains  the  skin,  and  in  some  cases 
pernicious  symptoms  are  developed  out  of  a  complicating  dysentery 
or  pneumonia.  Such  a  case  may  extend  over  two  weeks,  and  gradu- 
ally abate  into  an  intermittent,  or  terminate  fatally,  with  pernicious 
phenomena,  in  collapse.  In  the  grave  fortn  the  case  may  begin  as  in 
the  severe  variety  :  in  the  first  week  the  exacerbations  and  remissions 
will  be  irregular,  perhaps,  with  a  tendency,  constantly  increasing, 
toward  a  continued  type,  delirium  and  stupor  coming  on,  and  deepen- 
ing into  coma.  Instead  of  a  gradual  progress  toward  a  typhoid  state, 
the  case  may  begin  with  serious  symptoms,  and  in  a  few  hours  deliri- 
um, jaundice,  haemorrhages,  albuminuria,  or  suppression  of  urine  may 
appear.  In  other  cases,  choleraic  symptoms  or  dysentery  may  come 
on,  purulent  effusions  into  the  serous  sacs  may  occur,  a  pneumonia  may 
develop,  abscess  may  form  in  the  liver,  and  gangrene  of  the  skin  may 
result.  A  form  of  remittent  fever  of  great  severity,  and  having  close 
analogies  with  yellow  fever,  is  that  known  as  the  hcemorrhagic  bilious 
fever.  It  may  commence  as  an  ordinary  intermittent,  but  the  grave 
symptoms  rapidly  develop.  The  chills  are  protracted  and  violent, 
intense  headache  and  backache  are  then  experienced,  a  burning  pain 
passes  from  the  pharynx  to  the  stomach,  very  depressing  nausea  now 
comes  on  with  vomiting  of  bilious  matter,  obstinate  constipation  is 
succeeded  by  a  bilious  diarrhoea,  the  urine  is  copious  and  dark  in  color, 
the  skin  assumes  an  icteric  hue,  and  very  considerable  swelling  of  the 
spleen  and  liver  occurs.  Meanwhile  the  fever  becomes  remittent  and 
the  remissions  less  and  less  marked,  the  pulse  rapidly  declines  in  vol- 
ume and  strength,  the  skin  is  covered  with  a  cold  sweat,  the  features 
shrink,  haemorrhages  occur  from  the  mucous  surfaces,  the  urine  lessens 
greatly  in  quantity  or  is  entirely  suppressed,  and  the  fatal  result  is 
reached  in  an  increasing  coma.  Notwithstanding  the  formidable 
character  of  this  variety  of  remittent  fever,  a  fatal  result  is  not  inevi- 
table, if  the  subject  be  vigorous,  and  the  treatment  properly  carried 
out  before  the  onset  of  coma,  which  may  appear  on  the  fourth,  fifth,  or 
sixth  day.  So  strong  is  the  resemblance  of  these  cases  to  yellow  fever 
50 


786  MALARIAL  DISEASES. 

that  they  are  doubtless  often  confounded  during  the  epidemic  preva- 
lence of  the  latter.  Ko  means  of  distinction  between  them  is  so  satis- 
factory as  the  action  of  quinia,  which  will  arrest  the  one  but  not  affect 
the  other. 

Treatment. — The  questions  of  public  and  private  hygiene  involved 
in  the  prevention  of  malaria  are  beyond  the  scope  of  this  work.  The 
direction  which  the  investigation  ©f  physicians  should  take  is  in- 
dicated in  the  etiological  chapter.  The  measures  of  prophylaxis,  as 
affecting  individuals,  must,  however,  receive  some  attention.  Those 
living  in  malarious  regions,  susceptible  to  the  action  of  the  poison, 
must  avoid  all  excesses  of  every  kind,  exposure  to  fatigue,  to  heat,  and 
to  rapid  alternations  of  temperature.  Exposure  to  the  night  air  and 
to  the  early  morning  air  is  also  to  be  avoided.  Before  leaving  the 
house  in  the  morning  a  substantial  breakfast  should  be  taken,  and  a 
prophylactic  dose  of  quinia  if  the  season  of  malarial  production  has 
arrived — summer  and  fall.  The  experience  now  accumulated  as  to  the 
prophylactic  power  of  quinia  puts  this  question  beyond  controversy. 
The  English  naval  experience  on  the  coast  of  Africa,  the  military  ex- 
periences in  India  and  Africa,  and  our  own  experience  during  the  civil 
war,  have  demonstrated  that  the  daily  administration  of  a  sufficient 
dose  will  procure  immunity  against  malarial  infection.  The  quantity 
required  for  this  pm'pose  is  differently  stated,  but  should  be  determined 
by  the  supposed  intensity 'of  the  malarial  poison,  and  may  be  put  at 
from  five  to  ten  grains  daily.  It  is  best  administered  in  the  early 
morning,  and  in  some  black  coffee,  or  dissolved  by  the  aid  of  sulphuric 
acid  in  water,  in  pill-form,  or  simply  in  water.  The  practice  pursued 
in  our  army  during  the  war,  of  giving  quinine  in  whisky,  is  wrong  in 
principle,  and  the  results  were  not  good,  therapeutically  or  morally. 
The  effects  of  quinia  as  a  prophylactic  are  much  more  certain  than 
when  used  in  a  correspending  way  to  prevent  relapses.  In  fact,  it  is 
much  easier  to  prevent  than  to  cure  the  disease.  If  there  is  no  time 
to  prevent  the  paroxysm,  we  possess  means  to  abort  it  at  the  chill 
stage.  The  expedients  resorted  to  for  this  purpose  are  very  numer- 
ous, and  include  nitrite-of-amyl  inhalations  ;  chloroforra  by  inhalation 
and  by  the  stomach  ;  the  hypodermatic  injection  of  morphia  and  of 
pilocarpine.  From  a  half -drachm  to  a  drachm  (fluid)  of  chloroform, 
given  in  some  sweetened  watei',  by  the  stomach,  or  administered  by 
inhalation,  will  usually  arrest  the  chill,  and  greatly  lessen  the  severity 
and  duration  of  the  succeeding  stages.  Amyl  nitrite  is  also  quite 
efiicient  in  bringing  on  reaction  and  abbreviating  the  chill  stage,  but  it 
exercises  little  or  no  influence  on  the  other  stages.  Recent  observa- 
tions seem  to  prove  that  pilocarpine,  of  all  the  remedies  hitherto  pro- 
posed for  this  purpose,  exercises  the  most  remarkable  influence.*     If 

*  Dr.  Griswold,  August  16,  1S79,  "  New  York  Medical  Record." 


REMITTENT   FEVER.  787 

administered  as  the  chill  is  coming  on,  it  stops  it,  and  substitutes  a 
sweating  stage,  thus  preventing  the  full  evolution  of  the  paroxysm. 
The  most  remarkable  point  is  that  the  disease  seems  arrested,  and 
relapses  prevented,  in  a  considerable  proportion  of  the  cases.  If  these 
observations  are  confirmed,  we  shall  have  in  pilocarpine  the  most  use- 
ful remedy  in  the  treatment  of  intermittents.  From  one  twelfth  to 
one  sixth  grain  of  the  nitrate  or  muriate  of  pilocarpine,  given  hypo- 
dermatically,  is  the  appropriate  dose  for  an  adult,  and  this  should 
be  given  as  the  chill  is  about  to  occur.  A  corresponding  dose  (one 
sixth  to  one  fourth  grain)  can  be  given  by  the  stomach  half  an  hour 
before  the  chill-time.  If  the  chill  has-  anything  of  the  pernicious  char- 
acter about  it,  the  most  efficient  remedy  is  the  hypodermatic  injec- 
tion of  morphia  and  atropia,  or  of  morphia  alone.  In  any  of  the 
modes  in  which  the  pernicious  attacks  come  on,  the  remedies  are  two 
— morphia  and  quinia— and  the  mode  of  administration  subcutaneous. 
The  usual  means  of  applying  artificial  heat  are  of  course  to  be  used, 
but  no  time  should  be  expended  on  anything  until  moi'phia  and  quinia 
shall  have  been  injected  subcutaneously.  From  one  twelfth  to  one 
fourth  of  a  grain  of  morphia  can  be  given  to  an  adult.  Maximum 
doses  of  quinia  are  required.  Much  difficulty  has  hitherto  been  ex- 
perienced in  preparing  a  suitable  solution  of  quinia.  As  the  muriate 
of  quinia  and  the  bromide  are  soluble  to  a  much  larger  extent  than  the 
sulphate,  they  may  be  iised  for  solution  in  water  only ;  but,  as  the 
quantity  required  is  so  great,  a  solution  of  the  sulphate,  dissolved  by 
the  aid  of  sulphuric  acid,  is  generally  preferred.*  The  dose  of  quinia 
injected  in  a  pernicious  case  should  not  be  less  than  twenty  grains, 
and  this  may  be  repeated  two  or  three  times  until  reaction  is  estab- 
lished. In  the  absence  of  the  method  or  means  of  hypodermatic  in- 
jection, quinia  and  morphia  may  be  administered  by  the  rectum,  if 
insensibility  or  irritability  of  the  stomach  prevents  the  introduction  of 
remedies  into  that  viscus.  If  the  approach  of  a  pernicious  intermittent 
is  indicated  by  the  presence  of  head-symptoms — drowsiness,  headache, 
vertigo,  etc. — the  administration  of  full  doses  of  quinia  should  not  be 
delayed. 

In  the  treatment  of  ordinary  intermittents,  our  attention  is  directed 
to  the  prevention  of  future  attacks.  Although  no  preparatory  treat- 
ment is  actually  required,  better  results  are  obtained  if  the  gastro- 
intestinal derangement  is  removed.     If  the  tongue  is  heavily  furred, 

*  R.  Quinice  disulph.  gr.  50. 

Acid,  sulphuric,  dil.  til  100. 
Aquae  font.  §  j. 
Acid,  carbol.  liq.  v\  5. 
Solve. 
For  various  formulae,  see  "  Manual  of  Hj^jodermic  Medication,"  by  the  author  of  this 
work,  third  edition,  p.  213. 


Y88  MALARIAL  FEVERS. 

the  stomach  irritable,  and  the  bowels  constipated,  the  absorption  of 
quinia  is  much  hindered  and  its  powers  lessened.  A  grain  of  calomel, 
followed  in  four  or  six  hours  by  a  sedlitz-powder,  or  the  latter  with- 
out the  calomel,  will  assist  in  the  absorption  of  the  quinia.  The  old 
plan  of  an  emetic,  followed  by  "ten  of  ten" — ten  of  calomel,  ten  of 
jalap — is  no  longer  pursued.  Opinions  still  differ  as  to  the  period  of 
administration,  and  the  dose  of  quinia,  in  the  treatment  of  intermit- 
tent fever  ;  but  these  differences  exist  among  those  only  who  have 
but  limited  experience  in  the  management  of  severe  intermittents. 
The  question  is,  shall  we  use  small  doses,  frequently  repeated  in  the 
interval,  or  a  single  full  dose  at  the  proper  period  before  the  access 
of  the  paroxysm.  The  latter  is  better  for  these  reasons  :  the  whole 
effect  of  the  quinia  is  obtained  at  the  right  time,  a  less  quantity  suf- 
fices, and  the  curative  effect  is  greater.  As  the  elimination  of  quinine 
takes  place  with  considerable  rapidity,  appearing  in  the  urine  in  three 
hours  after  it  is  swallowed,  it  is  obvious  that,  if  the  administration 
has  been  distributed  over  twelve  hours,  the  effects  of  the  first  doses 
are  expended  before  the  last  are  given.  The  amount  necessary  to 
arrest  the  paroxysms  should,  therefore,  be  given  at  a  dose,  or  within 
a  short  period,  and  at  a  time  preceding  the  chill  sufficient  to  obtain 
the  maximum  effect,  which  is  about  three  hours.  For  an  ordinary 
intermittent  from  fifteen  to  twenty  grains  of  quinia  are  necessary  to 
stop  the  paroxysms.  To  prevent  relapses,  quinia  must  be  given  at 
certain  periods  :  on  the  second  or  third  day,  and  on  the  fourth  and 
sixth  days  after  the  date  of  the  first  administration,  according  to  the 
type.  Having  in  view  the  tendency  to  relapse  at  subsequent  jDeriods, 
quinia  should  be  again  given  on  the  twelfth  to  the  fourteenth,  and  on 
the  nineteenth  to  the  twenty-first  days.  As,  in  cases  of  malarial 
cachexia,  we  have  to  deal  with  certain  morbid  conditions  of  the  liver, 
spleen,  intestines,  blood,  etc.,  attention  must  be  given  to  them  if  we 
would  effect  a  cure.  To  improve  the  condition  of  the  blood,  the 
chalybeates,  notably  the  sulphate  of  iron,  must  be  employed  ;  and  these 
remedies  are  the  more  efficacious  if  combined  with  arsenic  and  other 
tonics.  During  the  intervals  between  the  administration  of  quinia, 
the  remedies  best  adapted  to  the  existing  state  of  malarial  cachexia 
are,  besides  iron,  arsenic  and  eucalyptus.  Various  substitutes  for 
the  expensive  quinia  are  now  largely  administered.  Probably  the 
best  of  them  are  the  combined  alkaloids  of  cinchona  in  an  impure  form, 
as  used  by  the  authorities  of  India.  Quinidia  may  be  prescribed  in 
the  same  quantity  as  quinia,  and  seems  about  as  effective.  Cinchonia 
is  also  quite  effective  in  twice  the  quantity  as  quinia.  The  author  has 
found  hydrastia,  the  alkaloid  of  hydrastis,  quite  a  good  antiperiodic, 
and  next,  probably,  to  the  alkaloids  of  cinchona  in  power.  Salicylic 
acid  has  some  antiperiodic  property,  but  greatly  inferior  to  quinia  ;  it 
has  been  combined  with  quinia  to  form  salicylate,  but  such  combina- 


REMITTENT   FEVER.  789 

tions  are  of  doubtful  value.  Eucalyptus  is  a  most  useful  antiperiodic, 
but  it  is  adapted  rather  to  the  treatment  of  malarial  cachexia,  and  to 
prevent  relapses.  Iodine  possesses  a  high  degree  of  utility  in  the 
treatment  of  malarial  intermittents,  and  may  be  used  in  substitution 
for  quinia,  or  to  remove  some  of  the  secondary  lesions.  Lugol's  solu- 
tion is  a  convenient  form  in  which  to  administer  it.  The  combination 
of  iodine  and  carbolic  acid  is  highly  efficient  (IjL.  Acid,  carbol.  3  j, 
tinct.  iodinii  comp.  3  iij.  M.  Sig,  Four  drops  every  four  hours  in  suf- 
ficient water).  This  combination  may  be  depended  on  exclusively  in 
some  cases.  For  the  removal  of  the  various  morbid  alterations  caused 
by  malaria,  the  combination  of  iodide  of  ammonium  and  arsenic  is 
most  effective  (to  a  solution  of  iodide  of  ammonium,  giving  five  grains 
to  the  dose,  add  three  drops  of  Fowler's  solution).  The  practitioner 
will  find  this  most  useful  in  cases  of  chronic  malarial  poisoning  with 
frequent  intermittents.  For  the  treatment  of  enlarged  spleen  there 
is,  besides  the  exhibition  of  quinia,  no  remedy  more  efficacious  than 
the  ointment  of  the  red  iodide  of  mercury,  which  is  rubbed  in  daily 
over  the  splenic  region  in  the  sunshine,  until  soreness  of  the  skin  com- 
pels a  suspension.  For  the  gastro-intestinal  catarrh,  the  duodenal 
catarrh,  and  the  catarrhal  jaundice,  which  occur  so  frequently  in 
malarious  regions,  with  or  without  any  febrile  movement,  the  most 
serviceable  remedies  are  two,  the  pyro-phosphate  of  soda,  three  times 
a  day,  and  a  morning  and  evening  dose  of  ten  grains  of  quinia. 

In  the  treatment  of  remittent  fever  the  same  general  plan  is  to  be 
pursued  as  in  the  management  of  intermittents.  It  is  not  necessary 
to  await  the  remission,  but  the  antiperiodic  may  be  given  at  once,  yet 
it  is  certainly  true  that  the  remedy  in  corresponding  dose  is  much  more 
efficient  if  given  during  the  sweating.  The  author's  first  experience  in 
the  administration  of  large  doses  of  quinia  was  gained  under  that  able 
physician  and  medical  officer,  the  late  surgeon  John  M.  Cuyler,  M.  D., 
of  the  Army  Medical  Staff,  then  stationed  (1857)  at  Fort  Leaven- 
worth, Kansas.*  The  author,  a  recent  graduate  in  medicine,  and  just 
then  admitted  to  the  army,  was  very  fortunate  in  being  able  to  wit- 
ness the  practice  of  so  experienced  and  able  a  physician.  The  large 
hospital  of  the  post  contained  a  number  of  the  severe  remittent  fevers 
of  that  locality.  They  were  broken  up  into  intermittents  and  sent 
out  of  the  hospital  in  a  week,  usually  by  the  routine  prescription  of 
thirty  grains  of  quinia  the  first  morning,  twenty  the  second,  fifteen  the 
third,  and  ten  the  fourth — single  doses,  and  all  taken  at  once.  As  re- 
mittent fever  is  due  to  a  more  intense  and  concentrated  poison,  no 
delay  in  the  efficient  use  of  quinia  is  proper.  The  intermittent  remain- 
der requires  the  same  management  as  an  ordinary  intermittent.  Should 
there  be,  as  is  usual,  great  irritability  of  the  stomach,  quinia  solution 

*  To  the  United  States  Army  Medical  Staff  is  due  the  credit  of  first  using  large  doses 
of  quinia.     (See  reports  from  1839  to  1855.) 


790  DISORDERS   OF   NUTRITION. 

can  be  given  by  the  rectum,  and  the  usual  remedies  applied  for  the 
relief  of  the  nausea  and  vomiting.  If  the  rectum  is  also  irritable  and 
rejects  the  remedy,  it  must  then  be  given  hypodermatically.  When- 
ever it  is  practicable  to  do  so,  the  antiperiodic  should  be  administered 
during  the  remission  in  the  sweating  stage.  The  almost  numberless 
masked  intermittents  and  remittents  require  the  same  management  as 
an  ordinary  case  of  intermittent,  except  that  they  are  more  difficult  to 
arrest,  and  require  maximum  doses  of  quinia. 


DISORDERS   OF   NUTRITION. 


SCROFULA. 

Definition. — By  scrofula  is  meant  a  constitutional  dyscrasia,  heredi- 
tary or  acquired,  characterized  by  changes  inflammatory  and  hyperplas- 
tic, occurring  for  the  most  part  in  the  lymphatic  system,  the  skin, 
mucous  membranes,  connective  tissue,  osseous  structures,  and  viscera. 
Scrofula  is  also  known  as  struma,  the  strumous  diathesis,  tuberculosis, 
the  tuberculous  diathesis,  etc. 

Causes. — Heredity  is  the  most  influential  factor  in  its  pathogenesis, 
but  it  is  the  predisposition  and  not  the  disease  itself  which  is  inherited. 
Those  cases  ai'e  said  to  be  innate  in  which,  owing  to  conditions  pres- 
ent in  the  parents,  not  themselves  strumous,  a  scrofulous  constitution 
is  transmitted  to  their  offspring.  Such  conditions  are  old  age,  blood- 
relations,  cachexia  of  syphilis,  etc.,  which  existing  in  the  parents,  the 
offspring  may  possess  the  strumous  constitution.  Acquired  scrofula  is 
the  product  of  various  evil  hygienic  influences,  as  crowding,  bad  air, 
poor  food,  insufficient  clothing,  overwork,  especially  in  youth,  and  in 
dark,  damp,  and  crowded  apartments.  Recent  observations,  especially 
those  of  Cohnheim,  which  indicate  the  essentially  infective  nature  of 
tubercle — a  product  of  scrofula — show  the  great  danger  of  inducing 
tuberculosis  in  children  by  the  consumption  of  milk  from  tuberculous 
cows.  It  is  probable  that  many  cases  of  acquired  scrofula,  especially 
in  cities,  are  derived  from  this  source.  If  a  scrofulous  predisposition 
exist  in  a  latent  state,  it  may  be  roused  into  activity  by  various 
causes.  Certain  diseases,  as  measles,  whooping-cough,  typhoid  fever, 
etc.,  will  have  this  effect.  Scrofula  manifests  itself  usually  about  the 
time  of  the  first  dentition,  and  increases  from  the  third  to  the  sev- 
enth year.     It  is  rare  for  the  manifestations  to  appear  only  after  pu- 


SCROFULA.  791 

berty.  Glandular  affections  do  not  often  occur  before  the  second  year. 
Scrofula  prevails  under  all  conditions  of  soil,  climate,  and  elevation,  but 
it  occurs  most  frequently  in  those  countries  where  crowding,  bad  air, 
and  the  other  hygienic  evils  of  dense  populations  are  most  abundant. 

Pathological  Anatomy. — The  anatomical  changes  occur  in  the  lym- 
phatics, the  skin,  the  mucous  membranes,  the  bones  and  the  viscera. 
As  regards  the  lymphatics,  the  cervical,  bronchial,  mesenteric,  inguinal, 
and  others  are  affected  by  two  processes — one,  and  the  simplest,  con- 
sisting of  hyperplasia  of  the  gland-elements  ;  the  other,  and  more  com- 
plex, being  the  formation  and  subsequent  caseation  of  tubercle.  From 
the  hyperphasia  may  proceed  an  inflammatory  process,  involving  not 
only  the  gland  but  the  adjacent  connective  tissue  and  skin  ;  suppura- 
tion takes  place,  abscesses  form,  and  fistulous  tracks  and  sinuses  are 
made  by  the  discharge  of  pus.  The  first  step  in  the  caseation  of  the 
gland  is  an  enlargement  by  hyperj)lasia,  then  miliary  tubercles  form, 
or,  without  them,  cheesy  masses  develop  in  distinct  layers  from  the 
hyperplastic  materials,  and  ultimately  the  whole  gland  becomes  case- 
ous. It  is  a  disputed  question  whether  there  is  a  necessary  devel- 
opment of  the  miliary  tubercle  precedent  to  cheesy  degeneration,  or 
whether  the  process  of  caseation  develops  out  of  the  new  hyperplastic 
materials.  It  is  probable,  as  stated  above,  that  both  processes  share  in 
the  production  of  the  result.  The  cutaneous  manifestations  of  scrof- 
ula consist  in  eczematous  and  impetiginous  ei'uptions,  situated  on  the 
face,  scalp,  or  behind  the  ears  ;  and  at  the  nose  prominent  pustules  of 
impetigo  with  thick  yellow  crusts  and  suppurating  beneath,  the  adja- 
cent nasal  mucous  membrane  ulcerating,  are  the  characteristic  appear- 
ances. The  mucous  manifestations  of  scrofula  are  usually  situated  at 
or  near  the  junction  of  the  membrane  with  the  external  integument, 
and  the  cutaneous  lesions  are  associated  with  the  mucous.  Thus,  im- 
petigo of  the  lip  is  coincident  with  a  scrofulous  coryza  ;  otitis  externa 
with  retro-auricular  eczema  ;  catarrhal  conjunctivitis  with  eczema  of 
the  neighboring  cheek.  Strumous  coryza  after  some  years  becomes 
an  ozoena,  and  affects  by  contiguity  the  post-nasal  fossa.  The  mucous 
membrane  of  the  larynx  and  bronchi,  of  the  genito-urinary  tract,  and 
of  the  intestinal  canal,  may  also  be  attacked.  The  broncho-pulmonary 
membrane  is  a  favorite  seat  of  strumous  changes,  and  here  they  mani- 
ifest  a  strong  tendency  to  ulcerative  action.  The  connective  tissue  is 
affected  by  abscesses  ;  the  joints  become  the  seat  of  chronic  synovial 
disease,  of  erosions,  caries,  etc.  ;  the  periosteum  inflames,  the  bones 
also,  and  caries  and  necrosis  are  ultimate  results  of  the  changes,  or  the 
primary  disease  may  arise  in  the  spongy  portion  of  bone,  especially  in 
the  vertebra,  and  the  epiphyses  of  the  long  bones.  In  the  viscera  the 
most  important  of  the  lesions  due  to  scrofula  are  those  of  the  lungs — 
cheesy  pneumonia,  phthisis,  etc.,  and  those  of  the  cerebellum,  pro- 
ducing large,  cheesy  nodules.      Amyloid  degeneration  of   the   liver. 


792  DISORDERS   OF  NUTRITION. 

spleen,  and  kidney ;  caseous  infiltration  of  the  supra-renal  capsules 
and  tuberculosis  of  the  testes  are  also  products  of  the  strumous  di- 
athesis. 

Symptoms. — There  are  t^vo  distinct  t}^es  of  the  scrofulous  consti- 
tution, the  light  and  the  dark,  the  irritative  and  the  torind.  In  the 
former  the  skin  is  white  and  transparent,  the  veins  showing  through 
with  great  distinctness,  and  blushing  taking  place  with  extreme  facility ; 
the  hair  is  soft,  long,  and  fine  in  texture,  and  usually  of  light  shade  ; 
the  eyes  are  large,  blue,  and  brilliant,  the  pupils  dilated,  the  sclerotic 
pearly  ;  the  muscles  are  soft  and  flabby,  the  weight  in  proportion  to 
size  small ;  the  mental  development  is  precocious,  and  puberty  antici- 
pates the  usual  period.*  The  torpid  form  is  characterized  by  a  thick, 
coarse,  and  rather  dark  skin,  a  considerable  preponderance  of  adipose 
tissue,  the  muscles  being  weak  and  relaxed ;  the  body  is  gross,  the 
appearance  puffy,  the  habit  torpid  and  heavy ;  the  head  is  relatively 
large,  the  nose  short  and  stubby,  the  upper  lip  thick  and  prominent ; 
the  neck  is  thick  and  deformed  by  enlarged  thyroid  or  other  enlarged 
glands ;  the  abdomen  is  swollen  and  rather  protuberant ;  the  legs 
small  and  relatively  short.  The  intellectual  powers  correspond  to  the 
physical — they  are  slow,  inactive,  and  wanting  in  strength.  Although 
typical  examples  of  these  two  forms  are  met  with,  many  cases  consist 
of  a  mingling  of  these  types.  They  present  the  usual  pathological 
conditions  from  infancy  up.  They  are  subject  to  attacks  of  coryza,  to 
scrofulous  ophthalmia,  to  otorrhoea  and  discharges  from  behind  the 
ears,  to  vesicular  and  pustular  eruptions,  etc.  Slight  wounds  of  the 
skin  are  followed  by  protracted  suppuration,  by  enlargement  of  the 
connected  chain  of  lymphatics,  and  they  heal  with  difficulty.  During 
the  first  dentition  obstinate  impetiginous  eruptions  appear  on  the  face 
and  scalp  (milk-crust),  and,  if  the  eruptive  diseases  attack  these  stru- 
mous subjects,  severe  nasal  catarrh,  otorrhoea,  and  unhealthy  ulcera- 
tions linger  long  afterward.  After  the  second  dentition,  the  lymphatic 
glands  begin  to  enlarge,  and  the  scrofulides,  or  scrofulous  skin  affec- 
tions, make  their  appearance — as  erythema,  eczema,  impetigo,  ecthyma, 
aud  also  lupus.  Then  follow  affections  of  the  mucous  membranes, 
which  are  usually  catarrhal,  the  discharge  being  yellow,  thick,  and 
drying  easily,  but  it  is  highly  irritating,  causing  about  the  nose,  for 
example,  obstinate  eczema.  The  nose  and  the  ear  are  special  seats  of 
scrofulous  suppuration  and  discharge.  The  eye  is  affected  by  scrofu- 
lous ophthalmia,  which  is  remarkable  for  its  persistence  and  severity, 
and  for  the  little  damage  done  to  the  organ,  if  the  affection  be  appropri- 
ately treated.  The  mucous  membrane  of  the  bronchi  is  a  favorite  seat 
of  scrofulous  inflammation,  leading  to  caseous  phthisis  and  tuberculo- 
sis.    The  lymphatic  glands,  as  has  been  described,  are  affected  in  two 

*  "  General   Pathology,"  Wagner,  translated  by  Drs.  Van  Duyn  and  Seguin,  New 
York,  18Y6,  p.  458. 


SCROFULA.  793 

modes — by  a  simple  hyperplasia,  and  by  cheesy  degeneration  and  tuber- 
culosis. When  the  affected  glands  become  very  large,  forming  great 
bundles,  the  surrounding  connective  tissue  undergoing  inflammation, 
the  change  consists  in  a  cheesy  degeneration  and  tuberculosis.  Ab- 
scesses may  form  by  suppuration  of  the  connective  tissue  ;  but  these 
are  superficial.  When  suppuration  occurs  in  the  substance  of  the 
gland,  the  skin  overlying  it  is  attached,  becomes  a  characteristic 
bluish-red  color,  and  ultimately  breaks,  the  gland  is  exposed,  and  an 
ulcer  is  formed,  having  undermined,  irregular,  and  livid  margins.  The 
ulcer  thus  formed  may  spread  for  some  distance  under  the  skin,  and 
sinuses  extend  in  various  directions,  and  often  burrowing  quite  widely. 
Healing  of  such  scrofulous  ulcers  does  not  take  place  until  the  remains 
of  the  cheesy  gland  are  finally  extruded,  and  a  large,  unsightly,  often 
thick  and  indurated  cicatrix  is  left.  Sometimes  the  glands  enlarge 
enormously,  but  do  not  inflame  and  suppurate.  Such  bunches  are 
often  seen  on  both  sides  of  the  neck,  filling  in  the  whole  space  from 
the  jaw  to  the  sternum,  and  extending  into  the  mediastinum.  When 
large  numbers  of  glands  enlarge  in  this  way,  phthisis  is  more  apt  to 
follow  than  in  the  other  form  characterized  by  suppuration,  according 
to  the  author's  observation.  The  most  severe  of  the  scrofulous  affec- 
tions are  those  of  the  bones  and  joints,  notably  fungous  arthritis  (Bill- 
roth). This  disease  appears  most  frequently  in  the  knee,  but  attacks 
the  other  joints  also,  is  very  chronic  in  course,  and  terminates  either 
fatally  or  in  an  anchylosed  joint.  Scrofula  also  attacks  internal  parts 
by  affections  of  the  lymphatics,  as  tabes  tnesenterica,  or  more  frequently 
as  cheesy  pneumonia.  The  nutrition  of  the  body  does  not  necessarily 
fail.  Large  ulcers  on  the  surface  are  not  incompatible  with  very  good 
health  and  considerable  embonpoint ;  but  protracted  suppuration  of 
bone,  disease  of  the  mesentery,  etc.,  make  serious  inroads  on  the  vital 
powers,  but  the  mischief  induced  by  the  amyloid  degeneration,  caused 
by  protracted  suppuration,  is  much  greater. 

Course,  Duration,  and  Termination. — The  course  of  scrofula  is  essen- 
tially chronic.  When  one  group  of  troubles  disappears,  another  group 
comes  on  the  stage.  Its  course  is  much  influenced  by  the  particular 
direction  taken  by  the  morbid  process,  whether  it  attacks  the  external 
lymphatics  or  those  of  the  mesentery,  the  nasal  mucous  membrane  or 
the  bronchial,  etc.  In  many  instances  the  morbid  influence  expires 
about  the  period  of  puberty  ;  in  others  at  this  period  phthisis  develops. 
During  the  course  of  scrofula,  general  miliary  tuberculosis  may  come 
on,  or  the  protracted  suppuration  may  cause  amyloid  degeneration  of 
important  internal  organs,  or  a  tuberculosis  of  the  cerebellum  may 
arise.  So  many  elements  enter  into  the  solution  of  the  problem  that 
the  duration  can  not  be  very  definitely  expressed,  and  the  termination 
is  affected  by  so  many  possible  complications  that  no  exact  limits  can 
be  set  for  it. 


794  DISORDERS   OF  NUTRITION. 

Treatment. — When  acquired,  the  treatment  of  scrofula  is  a  slow, 
difficult,  and  unsatisfactory  procedure.     Better  results  are  obtained  by 
prevention  when  the  existence  of  a  scrofulous  diathesis  is  suspected. 
Preventive  measures,  which  must  begin  at  birth,  consist  in  saving  the 
child  from  all  those  evil  hygienic  influences  which  are  the  chief  excit- 
ing causes.     A  scrofulous  mother  should  not  nurse  her  child,  which 
should  be  put  to  the  breast  of  a  healthy  and  vigorous  wet-nurse.    "When 
feeding  begins,  the  diet  should  be  properly  proportioned,  and  should  not 
be  composed  of  more  than  the  necessary  amount  of  starchy  food.    Abun- 
dance of  plain,  substantial,  and  easily  digested  aliment  should  be  sup- 
plied to  the  growing  child  ;  its  clothing  should  be  arranged  to  protect 
the  body,  allow  the  limbs  free  motion,  and  afford  the  necessary  warmth; 
confinement  in-doors,  especially  to  dark  and  damp  habitations,  should 
be  prevented,  and,  if  practicable,  a  healthy  country  life  should  be  fol- 
lowed up  to  puberty,  and  the  educational  training  should  be  conducted 
with  reference  to  these  essentials  of  the  bodily  training.     If  scrofula 
has  already  appeared  under  any  of  its  modes  of  manifestation,  the  hy- 
gienic rules  just  referred  to  are  even  more  necessary,  but  unfortunate- 
ly are  attended  with  less  success.     As  faulty  nutrition  is  an  important 
factor,  our  remedial  measures  should  be  early  directed  to  improve  the 
assimilative  functions.    The  mineral  acids  and  the  bitters  are  very  use- 
ful here.    One  of  the  most  serviceable  remedies  for  promoting  construc- 
tive metamorphosis  is  the  lactophosphate  of  lime,  which  is  best  admin- 
istered in  the  form  of  sirup.     For  this  may  be  substituted  the  "  phos- 
phates "  in  the  form  of  the  compound  sirup  ;  but  the  former  is  more 
efficient.    Cod-liver  oil  is  of  great  utility  in  scrofula,  but  it  is  better  to 
reenforce  the  oil  with  the  lactophosphate  of  lime.     If  suppuration  is 
going  on,  the  sulphides,  according  to  Ringer,  may  be  depended  on  to 
secure  the  rapid  closure  and  healing  of  the  surface  ;  but  the  author 
regrets  to  say  that  he  has  not  succeeded  so  well  with  these  remedies. 
If  anaemia  is  a  marked  feature,  the  chalybeates  are  useful.     The  author 
finds  the  sirup  of  the  iodides  of  iron  and  manganese  a  very  efficient 
preparation.      Iodine  has  had,  since  its  first  discovery,  considerable 
repute  as  a  remedy  for  scrofula,  but  this,  originally  derived  from  ob- 
servation of  its  effects  on  simple  goitre,  has  not  been  confinned  by 
further  experience  of  its  use  in  the  enlarged  glands  of  scrofula.    While 
this  is  true,  it  is  also  a  fact  that  the  iodides  of  iron  are  more  efficient 
than  the  other  chalybeates.     Other  remedies  advocated  for  scrofula 
are  the  chlorides  of  calcium  and  barium,  and  they  deserve  a  suitable 
trial  in  obstinate  or  protracted  cases.     A  number  of  topical  ajjplica- 
tions  have  been  proposed.     The  most  efficient  in  our  experience  is  the 
ointment  of  the  red  iodide  of  mercury.     This  can  not  be  used  when 
inflammation  has  begun  in  the  skin.     When  scrofulous  abscesses  form, 
the  pus  should  be  drawn  off  with  an  aspirator,  and  the  cavity  then 
injected  with  tincture  of  iodine.     When  there  are  open  ulcers,  an  ex- 


ACUTE   MILIARY   TUBERCULOSIS.  795 

cellent  application  is  iodoform  mixed  with  tannin,  the  powder  being 
blown  by  an  insufflator  into  all  the  crevices. 


ACUTE   MILIARY   TUBERCULOSIS. 

Definition. — Acute  miliary  tuberculosis  is  a  febrile  affection  due  to 
the  deposit,  generally,  through  the  body,  of  the  gray  tubercle-granule. 
It  should  not  be  confounded  with  j^hthisis  florida,  which  is  an  acute 
caseous  pneumonia. 

Causes. — The  gray  granulation,  or  miliary  tubercle,  consists  of  a 
fine  reticulation  of  fibers,  with  a  mass  of  epitheloid  cells  and  granules, 
and  often  having  a  giant-cell  for  its  center.  In  acute  miliary  tubercu- 
losis these  minute  bodies  are  widely  distributed  throughout  the  sys- 
tem. In  the  lungs  they  arise  from  the  irritation  of  old  lesions,  from 
cheesy  lymphatics,  etc.,  and  they  are  developed  in  various  organs  by 
the  irritation  of  caseous  deposits,  of  suppuration,  of  the  products  of 
serous  and  mucous  inflammations,  etc.  Acute  miliary  tuberculosis  is 
one  mode  of  dying  from  consumption.  That  the  gray  granulation  is 
deposited  throughout  the  body  under  the  influence  of  certain  kinds  of 
irritation,  it  is  necessary  that  a  peculiar  vulnerability  of  the  constitu- 
tion exist — in  other  words,  that  it  be  of  the  scrofulous  type.  These 
deposits  of  miliary  tubercle  may  occur  at  any  age,  but  most  usually 
from  puberty  to  middle  life. 

Pathological  Anatomy. — In  the  brain,  miliary  granulations  develop 
from  the  endothelium  of  the  lymph-spaces,  and  are  therefore  found 
chiefly  in  connection  with  the  pia  mater.  They  occur  also  in  the  other 
membranes,  and  in  the  choroid.  In  the  lungs  they  are  contained  in 
greater  numbers  than  elsewhere,  and  are  usually  associated  with  and 
dependent  on  other  changes  in  these  organs.  Nevertheless,  both  lungs 
may  be  infiltrated  throughout  with  the  gray  granule,  when  free  from 
any  source  of  irritation.  In  that  case  the  infection  is  found  to  proceed 
from  some  other  source — from  the  bronchial  glands,  genito-urinary 
tract,  or  elsewhere.  In  addition  to  the  tubercular  deposition,  the  mu- 
cous membrane  of  the  bronchi  is  generally  hyperaemic,  and  the  con- 
gestion increases  from  the  main  bronchi  downward.  There  is  also 
increased  secretion,  the  mucus  having  a  somewhat  adhesive  and  viscid 
character.  Miliary  granules  are  quite  abundantly  di-stributed  in  the 
pleura  and  peritoneum,  as  in  the  pia  mater.  The  liver,  spleen,  and  kid- 
neys, and  the  mucous  membrane  of  the  intestinal  canal,  are  also  more  or 
less  infiltrated.  About  the  site  of  each  granulation  there  is  a  patch  of 
hyper^emia,  due  to  the  presence  of  an  irritating  material.  As  so  many 
organs  are  simultaneously  invaded,  it  follows  that  their  functions  must 
be  disordered.  As  the  new  formation  develops  from  the  vessels,  some 
serious  changes  might  be  expected  in  the  composition  of  the  blood. 
Although  not  adequately  studied,  enough  is  known  to  show  that  the 


796 


DISORDERS   OF  NUTRITION. 


blood  is  much  altered.  In  the  lungs,  hypostasis  takes  place,  and  in 
various  dependent  situations  the  blood  transudes.  The  blood  itself  is 
dark,  and  not  readily  coagulable.  The  heart  is  soft  and  flabby  and  its 
tissue  easily  torn.  The  spleen  is  also  enlarged,  the  pulp  much  in- 
creased, and  of  a  dark-brown  color. 

Symptoms. — Acute  miliary  tuberculosis  may  arise  in  the  course  of 
phthisis,  when,  therefore,  are  exhibited  the  phenomena  of  a  new,  sud- 
den, and  general  infection  in  addition  to  the  previously  existing  mal- 
ady. It  may  begin  in  those  who  have  apparently  good  health,  because 
the  source  of  infection  is  dormant.  It  is  with  the  latter  class  that 
we  have  to  deal  here  ;  the  former  have  been  sufficiently  considered  in 
the  chapters  on  phthisis.  As  the  symptoms  of  pulmonary,  or  cerebral, 
or  of  intestinal  disturbance  may  predominate  in  different  cases,  divi- 
sions may  be  made  accordingly  ;  but,  without  refining  so  far,  it  will 
suffice  to  describe  the  disease  as  a  whole,  referring  to  these  peculiari- 
ties in  passing.  The  disease  sets  in,  after  several  days  of  general 
malaise,  with  a  chill  followed  by  fever,  or  there  is  more  or  less  chilli- 
ness for  the  first  day.  The  fever  soon  rises  to  a  considerable  eleva- 
tion ;  there  are  headache,  tinnitus  aurium,  wakefulness,  or  sleep  dis- 
turbed by  dreams,  epistaxis  sometimes  ;  the  countenance  is  dull,  the 
eyes  heavy,  and  the  prostration  is  great  from  the  beginning.  The 
appetite  is  gone,  the  bowels  are  confined,  but  are  moved  copiously  by 
mild  laxatives,  and  the  urine  is  scanty  and  high-colored.  Soon  after 
the  onset  of  the  disease,  a  short,  dry  cough,  which  is  very  harassing, 
comes  on,  but  the  most  important  symptom  connected  with  the  re- 
spiratory organs  is  a  greatly  increased  rapidity  of  breathing,  the  res- 


FiG.  46— Temperature  Curves  of  Acute  Miliary  Tuberculosis. 

pirations  numbering  forty,  fifty,  even  sixty  per  minute.  The  pulse 
is  con-espondingly  increased,  rising  during  the  maximum  to  140,  160, 
or  higher,  and  falling  not  below  120.     The  tension  of  the  pulse  is  low 


ACUTE   MILIARY   TUBERCULOSIS.  797 

(dicrotic)  and  the  action  of  the  heart  is  feeble.  The  fever  is  usually 
of  the  remittent  type  of  continued  fever,  or  it  has  more  of  the  remit- 
tent quality  of  malarial  fever,  or  of  hectic.  The  periods  of  remissions 
are  characterized  by  sweats.  The  circulation  in  the  extremities  is 
feeble  ;  the  finger-nails  are  blue,  the  lips  and  nose  have  also  a  cya- 
notic hue,  and  the  countenance  soon  becomes  dusky.  On  auscultation, 
some  moist,  crackling  rales  are  audible  over  the  chest,  but  there  is  no 
special  change  in  the  sonority.  The  difficulty  of  breathing,  noted  at 
the  outset,  increases  and  really  amounts  to  dyspnoea.  The  tongue 
becomes  dry ;  sordes  accumulate  about  the  teeth  ;  food  is  rejected  ; 
the  abdomen  swells  with  tympanites  ;  diarrhoea  supervenes,  the  stools 
being  thin  and  having  a  light-yellow  color  ;  the  spleen  can  be  made 
out  considerably  enlarged,  and  occasionally  rose-spots,  not  unlike  those 
of  typhoid,  appear  on  the  abdominal  wall.  After  the  first  few  days 
of  headache,  vertigo,  and  disturbed  sleep,  delirium  occurs,  but  at  this 
period  the  mental  disturbance  is  only  at  the  time  of  awaking  from 
sleep  ;  by  the  end  of  the  first  week  it  has  become  nearly  constant. 
In  some  cases,  so  preponderant  is  the  deposit  of  gray  granulations  in 
the  meninges  of  the  brain  that  the  symptoms  are  those  of  acute  men- 
ingitis. In  a  majority  of  the  cases,  however,  there  is  delirium  of  the 
low-muttering  character.  As  the  case  progresses,  a  condition  of  som- 
nolence comes  on  ;  the  delirium  is  less  and  less  active,  and  the  stupor 
soon  passes  into  coma.  When  this  condition  of  the  cerebral  functions 
is  reached,  the  dyspnoea,  before  so  marked  a  feature,  ceases  to  affect 
the  respiratory  center.  When  there  is  little  or  no  deposit  of  miliary 
granules  in  the  cerebral  meninges,  the  functions  of  the  brain  are  dis- 
ordered because  of  the  high  temperature  which  obtains  in  this  disease. 
The  cerebral  symptoms,  then,  are  those  of  depression — there  is  a  good 
deal  of  hebetude  of  mind,  followed  by  stupor.  Should  the  deposits  in 
the  lungs  be  much  in  excess  of  those  in  the  meninges,  the  cough,  the 
dyspnoea,  the  moist  rales,  etc.,  will  be  more  prominent  than  the  head 
symptoms.  When  the  intestinal  mucous  membrane  is  largely  infil- 
trated with  tubercle,  the  tympanites  and  the  diarrhoea  are  decided. 
In  every  case  when  fully  developed,  there  are  stupor  and  some  low 
delirium,  rapid  breathing,  cough,  and  dyspnoea,  until  coma  comes  on  ; 
high  temperature,  rapid  pulse,  and  weak  heart  ;  swollen  abdomen  and 
diarrhoea,  and  an  enlarged  spleen.  The  cases,  as  a  rule,  present  a 
striking  analogy  to  typhoid,  not  only  in  the  symptoms  as  above  de- 
tailed, but  in  the  physiognomy  of  the  patient,  the  decubitus,  the  utter 
prostration,  and  in  the  course  of  the  disease. 

Course,  Duration,  and  Termination. — The  course  of  an  acute  mili- 
ary tuberculosis  is  that  of  an  acute  febrile  affection.  The  severity  is 
determined  by  the  extent  of  the  tubercular  deposits.  The  high  tem- 
perature which  prevails  at  the  maxima  is  a  measure  of  the  diffusion  of 
the  tubercle-granules,  but  the  fever  in  turn  contributes  to  the  gravity 


798  DISORDEKS   OF  NUTRITION. 

of  the  case,  "by  inducing  tlie  same  parenchymatous  changes  which 
occur  in  typhoid.  The  cases  assume  somewhat  different  features,  as 
above  pointed,  out,  whether  the  cerebral,  the  pulmonary,  or  the  intes- 
tinal lesions  predominate.  The  most  usual  type  is  that  of  a  severe 
fever,  having  bronchial  and  intestinal  complications,  and  more  or  less 
mental  disturbance  due  to  high  temperature,  and  hence  frequently 
confounded  with  typhoid  fever.  The  duration  varies  somewhat  in 
the  different  cases,  being  about  four  weeks  in  the  largest  number,  but 
it  may  last  six  weeks  or  even  three  months.  It  is  hardly  doubtful 
that  death  is  the  invariable  termination.  The  mode  of  dying  is  by 
exhaustion  and  failure  of  the  heart,  by  pulmonary  obstruction  and 
dyspnoea,  and  by  a  gradually  deepening  coma. 

Treatment. — The  consideration  of  the  treatment  of  acute  miliary 
tuberculosis  is  a  rather  barren  subject,  since  it  does  not  appear  that 
any  remedy  has  the  least  influence  over  the  disease.  The  treatment 
must  hence  be  symptomatic,  and  confined  to  remedies  for  relieving 
the  abnormal  temperature,  or  for  maintaining  the  power  of  the  heart. 

RICKETS. 

Definition. — Rickets  is  a  constitutional  disease  of  childhood,  char- 
acterized by  a  disorder  of  nutrition  in  which  the  growth  of  the  bones 
is  irregular,  calcification  is  imperfect,  and  deformities  ensue.  It  is  also 
called  osteomalacia,  rachitismus,  rachitis,  etc. 

Causes. — Rickets  occurs  everywhere,  but  there  are  certain  parts  of 
the  globe  where  the  cases  are  more  numerous  than  elsewhere,  because 
the  conditions  are  more  suitable.  Over-populated  communities,  the 
people  poor,  and  living  in  dark  and  damp  habitations,  insufficiently 
fed  and  clothed,  are  the  social  circumstances  under  which  rickets  de- 
velops. It  is  common  in  the  great  cities  of  England,  and  of  Europe 
generally,  and  rather  infrequent  in  this  country.  Parry,*  it  is  true, 
reports  that  "  at  least  twenty-eight  per  cent,  of  all  the  sick  children, 
between  one  month  and  five  years  old,  that  have  come  under  his  ob- 
servation during  the  last  three  years,  have  been  rachitic."  This  state- 
ment is  based  on  observations  in  the  children's  department  at  the 
Philadeljihia  Hospital.  Meigs  and  Pepper,  also,  of  Philadelphia,  hold, 
on  the  contrary,  that  rickets  is  much  more  common  in  Europe  than 
in  this  country.  As  Gee  finds  that  the  proportion  of  " SOS  per  cent, 
of  sick  children  under  two  years  of  age  were  rickety,"  and  as  the 
proportion  for  the  principal  cities  of  Germany  is  25  per  cent,  for 
Dresden,  13-4  per  cent,  for  Prague,  and  11 'l  per  cent,  for  Berlin,  this 
country  is  rather  to  be  compared  with  England,  f     It  seems  to  the 

*" The  American  Journal  of  the  Medical  Sciences,"  January,  18Y2,  "Observations 
on  the  Frequency  and  Symptoms  of  Rachitis,"  etc.,  by  John  S.  Parry,  M.D.,  etc. 
f  Senator,  in  Ziemssen's  "  Cyclopaedia,"  vol.  xvi,  article  "  Rickets."  . 


RICKETS.  799 

author  that  Dr.  Parry's  estimate  is  much  too  high  for  this  country  as 
a  whole,  although  it  may  have  been  correct  for  the  limited  area  of  his 
observation.  The  disease,  although  more  prevalent  among  the  chil- 
dren of  the  squalid  poor,  also  occurs  among  the  well-to-do  classes. 
Certain  bodily  states  of  the  parents  may  exert  a  very  baleful  influence 
on  the  constitutions  of  their  offspring,  of  which  rickets  may  be  regarded 
as  an  example.  An  innate  tendency  to  rickets  is  a  result  of  marriages 
of  consanguinity,  or  of  those  too  old,  or  of  the  feeble  and  cachectic. 
While  Sir  William  Jenner  holds  that  rickets  is  not  inherited,  he  strongly 
insists  on  the  influence  of  the  health  of  the  mother  on  the  development 
of  rickets  in  the  child.*  All  the  causes  of  every  kind,  which  depress 
the  bodily  powers  of  the  mother,  increase  the  tendency  to  the  produc- 
tion of  rickety  children.  While  the  bodily  condition  of  the  mother  is 
much  more  intimately  concerned  than  that  of  the  father,  the  effect  of 
any  given  cachexia  is  much  more  certain  and  disastrous  when  both 
parents  are  affected.  The  rickety  constitution  may  also  be  inherited. 
Numerous  illustrations  of  this  fact  have  been  collected,  and  it  is  gen- 
erally admitted  by  authors,  but  is  denied  by  Jenner.  After  birth,  the 
hereditary  tendency  is  brought  into  an  active  condition  by  faulty  ali- 
mentation and  unhygienic  surroundings.  Rickets  also  occurs  in  the 
inferior  animals.f  The  recent  observations  on  "the  influence  of  certain 
specific  irritants  upon  osteoplastic  tissue  "  have  thrown  great  light  on 
the  production  of  rickets.  These  specific  irritants  are  phosphorus  and 
lactic  acid.  If  to  the  action  of  these,  when  introduced  into  the  econ- 
omy, is  added  a  deficiency  in  the  amount  of  lime-salts  contained  in 
the  food,  or  an  inability  to  appropriate  that  received,  there  will  be  pro- 
duced the  state  of  rickets.  Lactic  acid  is  abundantly  formed  in  the 
intestinal  canal  of  the  infant,  and  acts  as  an  irritant  of  the  osteoplas- 
tic tissue,  while  at  the  same  time  it  is  a  solvent  of  the  lime-salts,  and 
thus  effects  their  elimination.  J 

Pathological  Anatomy. — The  distinctive  lesion  of  rickets  is  a  pecu- 
liar alteration  of  the  osseous  tissue  of  the  body.  The  long  bones  are 
thickened  at  their  epiphyseal  extremity  ;  the  bones  generally  are  soft- 
ened, the  flat  bones  are  thickened ;  various  deformities  result  from 
the  action  of  mechanical  causes,  as,  for  example,  deformities  of  the 
chest,  distorted  spine,  bent  legs,  etc.  ;  arrest  of  growth,  not  only  of  the 
bones  themselves,  but  of  all  associated  parts  ;  related  lesions  in  the 
pericardium,  lungs,  and  capsule  of  the  spleen  ;  and  morbid  alterations 
in  the  nutrition  of  the  brain,  spleen,  liver,  lymphatic  glands,  and  mus- 
cles, etc.  (Jenner).     Besides  these  changes,  the  bones  are  found  in  a 

*  "Medical  Times  and  Gazette,"  May  12,  1860,  "A  Series  of  Three  Lectures  on 
Rickets." 

\  "  Die  Rachitis  bei  Hunden,"  vou  Dr.  W.  Schiitz,  Virchow's  "  Archiv,"  Band  xlvi, 
s.  350. 

I  Senator,  op.  cii. 


800  DISORDERS  OF  NUTRITION. 

highly  hypersemic  condition,  which  extends  to  the  periosteum,  sub- 
periosteal tissue,  and  the  medulla.  The  most  characteristic  changes 
are  those  occurring  at  the  junction  of  the  epiphysis  with  the  diaphysis. 
Calcification  of  the  proliferating  cartilage  corpuscles  goes  on  irregu- 
larly, and  the  medullary  spaces  extend  beyond  the  line  of  calcification. 
Hence  the  epiphysis  contains  cartilage  irregularly  interspersed  in  the 
ossified  portions,  and  the  medullary  spaces  are  irregularly  bordered  by 
cartilage  and  by  bone.  The  periosteum  is  equally  changed.  Besides  an 
intense  hyj)er8emia,  already  mentioned,  this  membrane  is  much  thick- 
ened, closely  adherent  to  the  bone,  and  its  cellular  elements,  rapidly 
proliferating,  are  being  converted  into  bone-cells.  When  flat  bones 
are  cut  across,  they  are  seen  to  be  highly  congested,  and  present  a 
reticulated  structure  under  the  periosteum  (Senator).  The  result  of 
these  changes  is,  that  the  bones  are  so  soft  that  they  can  be  easily  cut, 
and  bent  with  a  slight  force.  Chemical  examination  has  disclosed  im- 
portant changes.*  When  the  disease  is  far  advanced,  the  animal  mat- 
ter does  not  furnish  chondrin  or  gelatin,  and  gluten  has  been  obtained 
from  it.  Jenner  finds  that  while  the  bones  of  healthy  children  yield 
thirty-seven  parts  of  animal  and  sixty-three  of  mineral  substances,  the 
bones  of  rickety  children  yield  about  seventy-nine  parts  of  animal  and 
twenty-one  parts  of  mineral  matter.  Besides  the  alterations  of  bone, 
which  are  essential,  there  occur  lesions  in  other  organs,  some  of  which 
are  accidental,  as  the  intercurrent  diseases  ;  and  others  seem  to  have 
the  relation  of  effect,  as  chronic  diarrhoea,  enlarged  mesenteric  glands, 
fatty  degeneration  of  the  liver,  and  enlarged  spleen. 

Symptoms. — Rickets  begins  during  the  intra-uterine  life,  and  the 
characteristic  changes  have  been  recognized  in  the  foetus.  The  usual 
period  of  its  first  symptoms  is  from  the  fourth  to  the  seventh  month. 
It  is  a  disease  of  early  life.  The  cases  occurring  within  the  first  and 
second  year  greatly  exceed  all  of  the  subsequent  life.  When  the 
initial  symptoms  begin,  there  is  a  period  of  several  months  during 
which  the  nature  of  the  case  may  remain  in  doubt.  The  first  symp- 
toms are  connected  with  the  organs  of  digestion,  and  are  such  as  may 
arise  during  the  course  of  many  chronic  diseases.  It  is  observed  that 
the  child  wastes,  but  this  change  is  attributed  to  indigestion,  there 
being  more  or  less  diarrhoea  and  vomiting,  the  stools  and  the  matters 
vomited  having  an  acid  reaction.  The  stools  are  also  light  in  color, 
because  of  the  absence  of  bile,  and  have  an  odor  of  decomposition. 
The  appetite  is  wanting  entirely,  or  is  capricious,  and  vomiting  is  fre- 
quent. Besides  wasting,  the  child  grows  dull,  listless,  and  peevish ; 
there  is  some  fever  present,  and  intense  thirst  is  experienced,  the  child 
swallowing  enormous  quantities  of  water.  If  the  child  has  begun  to 
walk,  it  soon  becomes  too  feeble,  and  prefers  to  sit  or  lie  quietly,  and 

*  "  Ueber  Osteomalachia  und  Rachitis,"  von  Dr.  F.  Ruloff  in  Halle,  Virchow's  "  Archiv," 
Band  xxxvii,  s.  433. 


RICKETS.  801 

is  equally  indisposed  to  any  exertion  as  to  any  amusement.  Pains  in 
the  limbs,  especially  about  the  joints,  are  complained  of.  The  pulse 
is  quick  and  irritable,  and  the  superficial  veins  are  swollen.  The  ante- 
rior fontanelle  remains  open  and  does  not  diminish  in  area.  These 
symptoms  do  not  indicate  the  nature  of  the  disorder  which  is  now  de- 
veloping, but  certain  signs  of  high  significance  make  their  appearance 
after  a  variable  period  of  intestinal  troubles  and  impaired  nutrition. 
To  Sir  William  Jenner  we  owe  the  credit  of  having  emphasized  the 
importance  of  these  symptoms.  The  first  is  profuse  perspirations  of 
the  head,  neck,  and  upper  part  of  the  chest,  appearing  chiefly  while 
the  child  is  asleep,  but  at  the  same  time  the  abdomen  and  extremities 
are  dry  and  hot.  The  next  symptom  is  a  feeling  of  burning  heat, 
especially  in  the  lower  limbs,  impelling  the  child  to  kick  off  the  cov- 
ering and  keep  the  legs  exposed  to  the  external  air  in  cold  weather. 
The  third  symptom  is  tenderness  of  the  whole  body.  The  rickety 
child  does  not  play  and  toss  its  limbs  about  in  all  directions,  but  it 
keeps  as  motionless  as  possible,  and  cries  out  when  it  is  taken  up,  or 
moved,  or  pressed  on.  At  this  period,  also,  the  urine  is  abundant,  and 
deposits  a  copious  sediment  of  the  lime  salts.  The  child  at  this  period 
begins  to  have  a  peculiar,  a  characteristic  appearance.  It  is  languid, 
wasted,  its  countenance  wearied,  depressed,  and  aged,  the  face  has 
grown  broad  and  square,  the  hair  is  thin,  dry,  and  dead,  the  fontanelle 
is  open  widely,  the  muscles  are  wasted  and  flabby,  and  seem  unable  to 
support  the  body  erect,  the  head  sinks  between  the  shoulders,  and  the 
abdomen  is  swollen  and  protuberant.  Now  appear  the  changes  in 
the  bones  which  unmistakably  indicate  the  nature  of  the  case.  The 
extremities  of  the  long  bones  swell  and  have  a  knobby  appearance  ; 
they  yield  to  the  weight  of  the  body  or  the  action  of  the  muscles  and 
bend,  those  of  the  lower  extremities  forward  and  outward  and  the  fe- 
murs forward,  and,  if  the  child  is  walking,  outward  also.  At  a  more 
advanced  age,  the  curvature  of  the  lower  limbs  is  different ;  the  knees 
approximate  by  bending  of  the  femur  and  tibia  in  a  curve  whose  con- 
cavity is  toward  the  middle  line  of  the  body,  and  the  feet  are  turned 
away  from  each  other,  so  that  the  child  walks  on  the  ankle  and  inner 
side  of  the  foot  ;  or  the  bending  is  in  the  opposite  direction,  both 
limbs  bent  like  a  bow,  the  child  walking  on  the  outer  surface  of  each 
foot,  and  the  knees  widely  separated.  The  spine-curves  are  determined 
by  the  child's  walking  or  not  walking.  In  the  former,  the  natural  an- 
terior curvature  of  the  cervical  spine  is  greatly  exaggerated  ;  the  face 
is  turned  upward  and  the  head  falls  back,  and  if  the  muscles  are  very 
weak  the  head  is  not  supported  by  the  neck-muscles,  but  flops  about 
idly.  The  other,  or  posterior  curve  of  the  child  in  arms,  commences 
at  the  first  dorsal  and  extends  to  the  last  dorsal.  It  may  be  so  great 
as  to  be  mistaken  for  angular  curvature,  and  Jenner  proposes  to  dif- 
ferentiate by  simply  extending  the  child  ;  but,  in  old  cases,  the  vertebra 
51 


802  DISORDERS  OF  NUTRITION. 

and  intervertebral  disks  have  undergone  permanent  changes  and  can 
not  be  moved.  Lateral  and  outward  curvature  of  the  spine  also  takes 
place  ;  but  these  forms  are  less  common,  because  those  that  are  usual 
are  mere  exaggerations  of  normal  curves.  Important  changes  occur 
in  the  formation  of  the  thorax.  The  ribs,  being  softened,  yield  to  the 
atmospheric  pressure,  the  sternum  is  projected  forward,  thus  increasing 
the  antero-posterior  diameter  of  the  chest.  The  ribs  are  bent  poste- 
riorly to  an  acute  angle,  and  a  groove  is  formed  along  the  junction 
of  the  ribs  with  their  cartilages,  extending  from  the  first  to  the  ninth 
or  tenth  rib,  but  farther  down  on  the  left  side.  Owing  to  the  position 
of  the  heart,  the  chest-wall  of  the  prsecordial  space,  supported  also  by 
the  liver,  spleen,  and  stomach,  does  not  recede  and  hence  is  appar- 
ently more  protuberant.  Similar  curves  occur  in  the  upper  extremities, 
but  they  are  determined  by  the  age  and  the  muscular  actions  imposed  on 
these  members.  The  head  of  the  rickety  child  appears  larger  than  that 
of  a  healthy  child  of  the  same  age  ;  but  this  is  only  apparent  and  not 
real,  the  difference  being  due  to  the  wasting  of  the  face  and  neck  in 
the  former.  If  the  rickety  child  is  under  two  years,  the  fontanelle, 
which  normally  closes  by  this  time,  is  widely  open,  and  remains  open 
till  the  third  year  or  longer.  The  vertex  has  a  flat  shape,  the  forehead 
is  large  and  square,  and  the  parietal  bones  are  expanded.  The  bones 
of  the  face — the  upper  jaw  and  the  malar — cease  to  grow,  while  the 
frontal  and  ethnoidal  sinuses  expand,  and  hence  the  greater  j)rominence 
of  the  latter.  The  process  of  dentition  is  either  delayed,  or  it  is  en- 
tirely arrested,  or  the  teeth,  if  formed,  decay  and  fall  out.*  The  pel- 
vis, as  the  chest,  acted  on  by  the  weight  of  the  body  and  by  the 
muscles  attached  to  it,  is  deformed  in  various  ways.  The  sacrum  and 
pubis  may  be  approximated,  or  the  iliac  bones  may  be  distorted  in- 
wardly, or  the  outlet  may  be  changed  in  form  and  narrowed  by  the 
sacrum  bending  forward.  The  gastro-intestinal  disorders,  which  pre- 
cede the  osseous  changes,  continue  during  the  development  of  the 
latter.  Emaciation  goes  on  at  the  same  rate,  the  abdomen  enlarges 
still  more,  the  muscles  waste  and  grow  weaker,  there  is  less  and  less 
disposition  to  voluntary  exertion,  the  perspirations  are  more  free,  the 
thirst  increases,  the  bowels  become  more  irregular  and  the  evacuations 
more  unhealthy,  containing  little  or  no  bile,  are  fetid,  the  food  often 
passing  unchanged.  The  pains  in  the  bones  increase  in  severity,  and 
their  growth  ceases  entirely.  Progressing  in  this  way,  after  a  variable 
period,  the  case  is  terminated  by  some  intercurrent  malady,  or  by  the 
development  of  some  one  of  its  natural  sequelae,  or  by  restoration  to 
health. 

Course,  Duration,  and  Termination.— Cases  of  rickets  of  so  acute  a 
character  as  to  run  through  their  course  in  a  few  weeks  have  been  de- 

*  Dr.  Samuel  Gee,  "St.  Bartholomew's  Hospital  Reports,"  vol.  iv,  1868,  p.  69,  "On 
Rickets."     He  gives  the  case  of  a  boy  of  three  years,  who  had  cut  only  eight  teeth. 


RICKETS.  803 

scribed.  In  its  ordinary  form,  rickets  is  an  essentially  chronic  mal- 
ady, and  lasts  from  months  to  years,  often  many  years.  When  the 
disease  begins  very  early,  the  changes  are  more  extensive  and  severe  ; 
but  those  cases  are  more  slow  in  progress  which  begin  during  or  sub- 
sequent to  the  second  year,  and  they  are  hindered  in  growth  by  more 
or  less  prolonged  periods  of  improvement,  during  which  the  bone 
affection  subsides  and  the  intestinal  disorders  cease  for  the  time,  to 
be  resumed  when  the  exacerbations  come  on.  Those  cases  beginning 
after  the  first  dentition  pursue  a  milder  course,  and,  if  properly  man- 
aged, end  in  recovery,  but  with  the  deformities  and  arrested  growth 
of  the  period  of  the  disease  at  which  arrest  occurred.  Recovery  may 
take  place  in  those  cases  occurring  the  first  year  of  life.  When  such 
a  favorable  course  is  to  be  pursued,  the  teeth,  which  had  been  tardy 
in  making  their  appearance,  come  through  and  do  not  decay,  the  swell- 
ing of  the  bones  subsides,  the  appetite  improves,  and  the  nutrition  be- 
comes more  active.  Various  complications  arise.  Among  the  most 
common  are  catarrh  of  the  bronchial  tubes,  broncho-pneumonia,  capil- 
lary bronchitis,  congestion  of  the  lungs,  and  pleural  effusion.  Jenner 
strongly  insists  on  the  dependence  of  laryngisinus  stridulus  on  rickets, 
or  a  rickety  constitution.  The  gravity  of  slight  affections  of  the  tho- 
racic organs  is  much  increased  because  of  the  diminished  capacity  of 
the  thorax.  Enlarged  spleen  is  present  in  two  thirds  of  the  cases  prov- 
ing fatal.  Enlarged  lymphatics  also  may  be  associated  with  it,  and 
important  changes  in  the  blood  take  place,  a  very  severe  anaemia  re- 
sulting. Chronic  hydrocephalus  may  also  Occur  as  a  complication, 
and  death  is  not  unfrequently  caused  by  convulsions.  Protracted 
diarrhoea,  ulceration  of  the  intestine,  and  amyloid  degeneration  of  or- 
gans, may  also  appear  during  the  course  of  unfavorable  cases. 

Diagnosis. — When  rickets  is  fully  developed,  a  question  of  diagnosis 
can  scarcely  arise.  The  only  disease  with  which  it  may  be  confounded 
is  inherited  syphilis.  Rickets  does  not  appear,  as  does  syphilis,  during 
the  first  days  of  life.  The  "  snufiles  "  and  cutaneous  lesions  do  not  be- 
long to  rickets  ;  enlargement  of  the  ej)iphyses  of  the  long  bones  does 
not  belong  to  syphilis.  Local  deformities,  which  may  simulate  the 
changes  wrought  by  rickets,  are  distinguished  by  the  fact  that  the  lat- 
ter are  general  and  not  local. 

Treatment. — The  most  important  remedies  for  rickets  are  hygienical 
and  dietetic.  Good  air,  warm  clothing,  daily  bathing,  and  a  nutri- 
tious diet,  are  essential.  If  the  child  is  nursing,  the  milk  of  the  mother 
should  be  carefully  examined.  If  she  is  the  subject  of  syphilitic  in- 
fection, or  of  a  cachexia,  the  child  should  be  removed,  although  the 
milk  may  seem  to  be  entirely  healthy.  No  rickety  child  should  be 
"  raised  by  hand,"  if  practicable  to  avoid  it.  If,  however,  it  can  not 
be  nursed,  a  proper  diet  becomes  then  a  subject  of  high  importance. 
Good  cow's  milk,  diluted  by  one  third  to  one  fourth  of  lime-water,  is 


804  DISORDERS   OF   NUTRITION. 

the  most  suitable  aliment.  In  the  absence  of  this,  condensed  milk  may 
be  substituted.  Should  these  disagree,  as  shown  by  the  passage  of  a 
great  deal  of  casein  in  the  evacuations,  barley-water  with  one  fourth 
cream  added  is  an  excellent  substitute.  The  various  substitutes  for 
mother's  milk  or  infant  food,  offered  for  sale,  are  of  doubtful  propriety, 
since  they  usually  contain  an  excess  of  starchy  food,  or  are  prepared 
on  false  principles,  or  based  on  theory.  The  points  to  which  medici- 
nal treatment  should  be  directed  are  the  disorders  of  digestion,  the 
acidity  of  the  evacuations,  the  absence  of  bile,  and  the  waste  of  the 
lime  salts.  Lime-water  should  be  given  freely  with  the  milk,  or  car- 
bonate of  lime  in  small  quantity  may  be  stirred  in  the  milk.  Pepsin 
in  full  doses  is  highly  serviceable,  and,  if  there  are  vomiting  and  diar- 
rhoea, it  may  be  given  with  bismuth.  Pepsin,  with  diluted  muriatic 
acid  in  small  quantity,  is  also  useful,  the  acid  acting  the  part  of  an 
anti-ferment,  and  preventing  the  formation  of  lactic  acid.  Brandy, 
reenforced  as  to  its  astringency  by  a  few  drops  of  tincture  of  catechu, 
is  a  most  efficient  remedy  also,  both  to  counteract  the  depression  and 
to  act  as  an  anti-ferment  and  an  astringent.  Cod-liver  oil  is  the  most 
efficient  remedy  against  the  constitutional  condition.  Moreover,  cod- 
liver  oil  improves  the  digestion  and  changes  the  character  of  the  evac- 
uations. It  may  be  given  in  an  emulsion  with  lime.  The  dose  should 
not  exceed  half  a  drachm  to  one  drachm,  three  times  a  day,  but  it 
should  be  kept  up  faithfully  for  a  long  time.  Small  doses  of  iron,  the 
carbonate  saccharated,  the  most  easily  digested,  or  the  acetated  tinc- 
ture, or  the  bitter  wine  of  iron,  should  be  persistently  administered. 

LYMPHADENOMA. 

Definition. — By  lymphadenoma  is  meant  a  dyscrasic  affection,  char- 
acterized by  enlargement  of  the  lymphatic  glands  and  of  the  spleen, 
and  by  progressive  anaemia.  It  is  also  called  Hodgkin's  disease,  be- 
cause it  was  first  described  by  Dr.  Hodgkin  in  1832,*  and  is  known  as 
"  malignant  lymphoma,"  "  lympho-sarcoma,"  the  name  given  it  by  Vir- 
chow,  and  "  pseudo-lukemia,"  as  named  by  Cohnheim. 

Causes. — Little  is  known  as  to  the  influences  producing  the  disease. 
It  is  not  hereditary  ;  it  may  come  on  without  obvious  cause  in  an  in- 
dividual in  apparently  perfect  health  ;  it  is  three  times  as  frequent  in 
males  as  in  females,  and  is  more  common  in  youth  and  old  age  than  in 
the  middle  period  of  manhood,  but  it  may  occur  at  any  age. 

Pathological  Anatomy. — The  changes  peculiar  to  this  disease  are 
found  in  the  lymphatics  and  in  the  spleen.  In  advanced  cases,  all  the 
glands  of  the  body,  superficial  and  deep,  are  diseased,  and  the  adenoid 

*  " Medico-Chirurgical  Transactions,"  vol.  xvii,  1832,  p.  68,  "On  some  Morbid  Ap- 
pearances of  the  Absorbent  Glands  and  Spleen,"  by  Dr.  Hodgkin,  presented  by  Dr.  R. 
Lee,  read  January  10  and  24,  1832. 


LYMPHADENOMA.  805 

tissue  in  the  course  of  the  lymphatic  vessels  takes  on  an  overgrowth. 
The  cervical,  axillary,  inguinal,  retro-peritoneal,  bronchial,  mediastinal, 
and  mesenteric  are  in  turn  affected,  and  in  the  order  named.  Usually 
both  sides,  but  sometimes  only  one  side,  is  affected.  The  size  of  the 
glands  affected  ranges  from  a  filbert  to  a  hen's-egg,  and  when  a  group 
of  glands  is  enlarged  to  the  maximum  the  whole  collection  forms 
an  immense  tumor,  which  may  have  the  dimensions  of  a  child's  head. 
At  first  each  gland  is  separate  and  freely  movable  ;  at  length  the 
whole  group  forms  a  solid  mass  ;  but  other  glands  in  other  situations 
may  still  remain  mobile.  The  growth  may  ultimately  penetrate  the 
capsule  and  extend  into  surrounding  tissues,  and  may  even  perforate  a 
vessel.  The  solidification  of  a  group  of  glands  is  also  brought  about 
by  inflammation  of  the  surrounding  connective  tissue.  The  pressure 
of  the  enlarging  glands  may  cause  atrophy  of  neighboring  structures 
and  interfere  with  the  functions  of  organs.  Two  kinds  of  changes  are 
noted  in  the  glands  :  some  are  hard  and  others  soft,  but  those  which 
have  been  soft  may  become  hard.  Sometimes  it  is  the  large,  some- 
times the  small,  glands  that  are  hard.  On  section  of  an  affected  gland, 
the  difference  between  cortical  and  medullary  parts  has  disappeared  ; 
the  color  is  whitish  or  grayish,  with  here  and  there  a  spot  of  hyperse- 
mia.  The  soft  glands  contain  a  great  quantity  of  lymph-corpuscles 
(or  cells  strongly  resembling  them),  which  gradually  displace  the  septa 
of  the  gland,  and  thus  give  to  its  cut  surface  an  homogeneous  appear- 
ance. In  the  harder  glands,  the  firmness  of  structure  is  due  to  the 
development  of  fibroid  tissue,  which  takes  place  in  the  septa,  in  the 
reticulum,  and  in  the  walls  of  the  capillary  vessels.  Finally,  the  cells 
atrophy  and  disappear  before  this  growth  of  fibrous  tissue.  The  spleen 
is  enlarged  in  three  fourths  of  the  cases,  but  slightly  enlarged  in  marty 
of  these,  the  increase  in  size  being  due  to  simple  hypertrophy  in  a  few 
instances,  and  to  disseminated  growths  in  the  majority.  These  growths 
may  be  the  size  of  peas,  distributed  through  the  organ,  or  may  occur 
in  larger  nodules,  looking  like  suet,  as  Hodgkin  was  the  first  to  say. 
These  masses  are  not  inclosed  in  a  capsule,  but  are  surrounded  by  com- 
pressed splenic  pulp.  They  do  not  often  pierce  the  capsule  of  the 
spleen,  but,  if  large  and  numerous,  do  compress  the  splenic  pulp,  which 
atrophies.*  These  splenic  growths  correspond  closely  with  the  growths 
in  the  lymphatic  glands,  and  consist  of  the  same  cells  and  fibroid  tis- 
sue ;  and  infarctions  are  also  encountered,  f  In  some  cases,  the  mar- 
row of  bones  has  undergone  changes  ;  it  becomes  converted  into  a 
reddish-gray,  soft,  almost  fluid  material,  due  to  the  predominance  of 
lymphoid  cells,  and  other  and  larger  cells,  with  compound  nuclei.  This 
alteration  of  the  marrow  of  bones  is  not  unlike  that  which  occurs  in 

*  Virchow,  "Die  Krankhaften  Geschwiilste,"  zweiter  Band,  s.  735,  Fig.  203. 
f  Langhaus,  Virchow's  "  Arcliiv,"  Band  liv,  s.  512. 


806  DISORDEES   OF   NUTRITION. 

leucocythemia.  The  large  follicles  at  the  base  of  the  tongue  enlarge 
to  a  considerable  extent,  and  the  adenoid  tissue  of  the  intestinal  mu- 
cous membrane  and  of  the  tonsils  takes  on  the  same  kind  of  change  as 
the  lymphatic  glands.  One  tonsil  may  ulcerate,  while  the  other  is 
enormously  enlarged.  The  changes  occurring  in  the  adenoid  tissue  of 
the  solitary  glands  and  of  Peyer's  patches  may  result  in  great  thick- 
ening of  the  intestine  walls,  but  do  not  encroach  on  the  lumen  of  the 
bowel.*  The  liver  is  invaded  in  a  considerable  proportion  of  the 
cases  by  minute  lymphoid  growths,  varying  in  size  from  a  pin-head  to 
a  pea,  and  having  the  same  composition  as  those  of  the  spleen.  In 
other  cases  the  adenoid  tissue  is  not  disseminated  in  isolated  masses, 
but  accompanies  the  portal  vessels  occupying  the  interlobular  spaces, 
and  sending  processes  into  the  acini.  One  third  of  the  liver  may 
be  thus  occupied,  f  Fatty  degeneration  may  coincide  with  the  lym- 
phoid disease  in  the  liver,  adenoid  growths  occur  in  the  kidneys  also, 
and  chiefly  in  the  cortex.  The  growths  are  of  small  size — from  a  pin's- 
head  to  a  pea — and  are  disseminated  in  the  inter-tubular  spaces.  They 
cause  atrophy  by  pressure,  and  initiate  parenchymatous  degeneration 
with  the  usual  consequences.  The  same  growths  are  rarely  found  in 
the  ovaries  and  testes,  and  often  in  the  thymus.  The  lungs  may  be 
attacked  by  contiguity  of  tissue  from  the  diseased  bronchial  glands,  or 
by  the  vessels.  The  growths  found  in  the  lungs  are  small,  grayish, 
and  firm,  and  are  often  mistaken  for  tubercles  (GowersJ).  More  or 
less  effusion  occurs  in  the  thorax,  and  sometimes,  bat  rarely,  lymphoid 
growths  are  found  in  the  sub-pleural  tissue,  and  in  the  substance  of 
the  diaphragm.  Sometimes  the  heart  is  small ;  again  it  is  far  advanced 
in  fatty  degeneration  ;  only  rarely  have  the  characteristic  adenoid 
growths  been  detected  in  the  substance  of  the  organ.  Murchison§ 
records  an  adenoid  growth  of  the  dura  mater  above  the  foramen  mag- 
num, and  Hosier  one  above  the  foramen  opticum. 

Symptoms. — There  are  two  groups  of  symptoms  :  those  due  to  the 
disease,  per  se ;  those  due  to  the  interference  by  the  growths  in  the 
functions  of  various  organs.  As  regards  the  first  group  there  are  two 
distinctive  symptoms — the  enlarged  glands,  and  the  anaemia.  The  cer- 
vical lymphatic  glands  are,  in  a  majority  of  cases,  the  first  to  enlarge, 
and  the  others,  as  a  rule,  follow  in  the  order  which  has  been  already 
given.     In  a  few  instances  a  febrile  attack  accompanied  the  initial  trou- 

*  Moxon,  "Transactions  of  the  Pathological  Society,"  1873,  p.  101.  Murchison  had 
made  the  same  observation  in  a  case  of  the  same  kind,  "Pathological  Transactions,"  IS'ZO. 

•f-  Wilks,  "Guy's  Hospital  Reports,"  1865,  "Cases  of  Lardaceous  Disease  and  Allied 
Affections,"  p.  128,  "Peculiar  Enlargement  of  the  Lymphatic  Glands." 

X  Dr.  W.  R.  Gowers,  Reynolds's  "  System,"  vol.  iii,  American  edition,  article  "  Hodg- 
kin's  Disease."  The  author  has  to  express  his  indebtedness  to  this  elaborate  and  exhaus. 
tive  memoir  for  valuable  information. 

§  "  Transactions  of  the  Pathological  Society,"  1870,  p.  372.  A  full  history  of  the  dis- 
ease follows. 


LYMPHADENOMA.  g07 

ble  in  the  glands  ;  in  other  cases  the  irritation  of  some  glands,  tempora- 
rily and  from  trivial  causes  enlarged,  has  led  to  the  development  of  the 
general  disease,  but  some  kind  of  predisposition  must  have  existed. 
The  enlarged  glands  are  firm  or  soft,  and  are  painless  unless  nerves 
are  pressed  on.  Anemia  may  begin  and  be  considerably  advanced 
before  the  glandular  enlargements,  but  it  usually  succeeds  to  them. 
The  ansemia  of  lymphadenoma  is  like  the  anaemia  of  any  cachexia. 
The  functions  generally  are  depressed,  and  we  have,  in  addition,  the 
weak  heart,  the  breathlessness  on  exertion,  and  the  pallor  and  feebleness 
belonging  to  this  state.  The  number  of  white  corpuscles  in  the  blood 
is  not  in  excess  of  the  normal  in  the  majority  of  cases,  and  is  never 
considerably  above  noi'mal  in  any  case.  The  white-blood  corpuscles 
are  small,  as  a  rule,  and  vary  in  size.  The  red  corpuscles  are  reduced 
in  number,  and  in  some  cases  the  number  of  small  red  corpuscles  is 
large.  According  to  Gowers,  the  red  corpuscles,  as  counted  by  means 
of  the  hsemacytometer,  may  descend  to  sixty  per  cent,  of  the  normal 
in  a  subject  having  still  some  color.  Fever  occurs  in  about  two  thirds 
(Gowers)  of  the  whole  number  of  cases.  Fever  may  be  present,  also, 
as  a  symptom  of  some  intercurrent  febrile  affection  ;  but  it  is  a  part 
of  the  morbid  process  in  young  subjects.  Although  the  course  of  the 
fever  is  irregular,  three  types  are  known  :  a  continuous  type  with 
slight  diurnal  variations  ;  a  remittent  fever,  hectic  in  character  ;  and 
a  paroxysmal  fever,  with  intermissions  of  entire  cessation  of  fever  for 
several  days.  The  symptoms  due  to  pressure  are  as  various  as  the 
organs  pressed  on.  The  enlarging  cervical  glands  and  thyroid  press 
on  the  carotids  and  jugulars,  interfere  with  the  intra-cranial  circulation, 
producing  at  one  time  cerebral  anaemia,  at  another  time  passive  cere- 
bral congestion.  Deglutition  may  be  interfered  with  by  pressure  on  the 
pharynx  and  oesophagus,  voice  and  breathing  by  pressure  on  the  larvnx 
and  trachea.  The  glandular  swellings  in  the  chest  produce  all  the 
symptoms  of  intra-thoracic  tumors,  by  pressure  on  the  cardiac  branches 
of  the  sympathetic,  on  the  recurrent  laryngeal,  on  the  pneumogastric 
and  phrenic,  on  the  great  venous  trunks,  on  the  arteries,  and  on  the 
trachea,  bronchi,  and  oesophagus.  Within  the  abdomen  these  tumors 
may  compress  the  aorta  and  give  rise  to  the  symptoms  of  aneurism, 
the  stomach,  and  cause  nausea  and  vomiting,  the  portal  vein  and  he- 
patic duct,  and  induce  ascites  and  jaundice,  the  principal  nerves,  and 
arouse  pain,  and  the  great  veins,  producing  oedema  of  the  lower  ex- 
tremities. To  enumerate  all  the  symptoms  which  may  be  excited  by 
the  pressure  of  these  enlarged  glands  would  be  to  summarize  the  symp- 
toms which  may  be  expressed  by  any  disordered  organ. 

Course,  Duration,  and  Termination.— The  course  of  lymphadenoma  is 
chronic.  The  average  duration  of  fifty  cases  collected  by  Gowers  was 
nineteen  months;  of  eighteen  cases,  the  duration  was  less  than  one  year; 
of  fifteen  cases,  between  one  and  two  years.     In  the  only  case  which 


808  DISORDERS   OF  NUTRITION. 

the  author  has  had  in  his  own  charge,  the  duration  was  two  years. 
In  all  cases  the  initial  glandular  enlargement — cervical  usually — is 
followed  after  a  certain  interval  by  the  general  affection  of  all  the 
glands.  There  may  be  quite  an  interval,  sometimes  years,  however, 
between  the  local  and  systemic  affection.  The  course  of  the  disease 
may  be  influenced  by  complications.  The  anaemia  may  induce  various 
acute  inflammations — erysipelas,  superficial  abscesses,  etc.  Phthisis 
may  occur,  as  in  the  author's  case.  Death  is  usually  due  to  exhaustion, 
but  it  may  be  caused  by  pressure  on  the  trachea  and  asphyxia,  on  the 
oesophagus  and  starvation,  on  the  jugular  veins,  carotids,  and  convul- 
sions and  coma.  Certain  intercurrent  affections  may  cause  death,  as 
pneumonia,  cedema  of  the  lungs,  pleuritic  effusions,  etc. 

Diagnosis. — The  maladies  with  which  Hodgkin's  disease  may  be 
confounded  are  leucocythemia,  with  splenic  and  glandular  changes, 
and  scrofula.  In  splenic,  glandular  leucocythemia  the  changes  in 
the  glands  succeed  to  those  in  the  blood,  whereas  the  glandular  en- 
largement is  the  initial  fact  in  lymphadenoma ;  and,  further,  in  the 
latter,  the  relative  proportion  of  white  coi-puscles  is  not  increased  in 
the  majority  of  cases.  From  scrofula  the  distinction  is  made  by  the 
number,  extent,  and  volume  of  the  glands  in  lymphadenoma,  by  the 
extension  of  the  enlarged  glands  over  the  body,  by  their  permanence, 
by  the  anaemia,  and  by  the  pressure  symptoms  which  affect  so  many 
organs.  In  scrofula  the  enlarged  glands  are  found  in  one  situation, 
and  usually  about  the  neck  they  suppurate  ;  the  symptoms  are  limited 
to  the  affected  part,  and  there  is  neither  anaemia  nor  pressure  symj)toms. 

Treatment. — The  medicinal  treatment  of  Ijnnphadenoma  has  not 
been  very  satisfactory.  The  preparations  of  iodine  and  the  iodides 
have  been  largely  used  without  success.  L'on,  arsenic,  chloride  of 
gold,  mercurials,  have  also  been  given  without  material  change.  Phos- 
phorus has  appeared  to  do  good  in  a  few  cases — ^has  reduced  the  size 
of  the  glands  and  improved  the  condition  of  the  blood,  but  phosphorus 
has  such  a  destructive  effect  that  it  must  be  used  with  caution.  Cod- 
liver  oil  has  been  serviceable  in  some  cases.  Probably  the  best  course 
to  pursue  is  to  administer  cod-liver  oil  steadily,  to  give  minute  doses 
of  phosj^horus  for  a  few  weeks  at  a  time,  and  then  suspend  it ;  to 
continue  iron  and  quinia  as  long  as  possible,  and  to  improve  the 
hygiene  of  the  patient  in  every  way.  The  local  treatment  of  the 
enlarged  glands,  consisting  of  external  applications,  injections  of 
tincture  of  iodine,  and  of  arsenic,  etc.,  has  not  been  useful.  The 
single  expedient  which  has  done  real  good  is  the  extirpation  of  the 
glands  first  enlarged.  This  operation,  to  do  any  permanent  good, 
must  be  performed  before  diffusion  of  the  glandular  enlargements  has 
occurred. 


ACUTE   RHEUMATISM.  809 

ACUTE   RHEUMATISM. 

Definition. — Acute  rheumatism  is  a  constitutional  disease  charac- 
terized by  fever,  inflammation  of  the  joints  occurring  in  succession, 
and  by  a  tendency  to  attack  the  peri-  and  endocardium.  It  is  fre- 
quently called  articular  rheumatism,,  rheumatic  fever,  polyarthritis 
rheumatica,  etc. 

Causes. — The  vice  of  constitution  belonging  to  rheumatism  is  in- 
herited, but  it  is  not  possible  to  indicate  its  character.*  There  are 
three  types  of  bodily  conformation  in  which  rheumatism  occurs  :  the 
pale,  thin,  and  anaemic  subject ;  the  robust  and  vigorous  individual 
with  an  inherited  tendency  ;  and  the  obese,  often  given  to  the  consump- 
tion of  malt-liquors  and  having  a  form  of  acid  indigestion  (lactic  ?). 
Acute  rheumatism  is  most  frequent  in  youth  and  early  manhood, 
rarely  occurring  before  seven  and  after  fifty.  It  is  more  frequent  in 
men  than  in  wornen,  not  because  of  a  greater  susceptibility  to  the  dis- 
ease, but  because  men  are  more  exposed  to  the  influences  producing  it. 
The  liability  to  the  disease  is  increased  by  having  attacks,  and  a 
longer  interval  usually  separates  the  first  and  second  seizures  than  the 
second  and  third.  On  the  other  hand,  the  susceptibility  to  rheuma- 
tism lessens  with  increase  of  years.  Certain  diseases  dispose  to  attacks 
of  acute  rheumatism  :  thus  during  the  stage  of  desquamation  of  scar- 
let fever,  and  in  the  puerperal  state,  attacks  in  all  respects  the  same  as 
ordinary  rheumatic  fever  may  occur.  The  seasons  of  greatest  preva- 
lence are  winter  and  spring,  and  the  occupations  most  favorable  are 
those  in  which  there  is  the  most  frequent  exposure  to  inclement 
weather.  Protracted  stay  in  damp  apartments,  lying  between  damp 
sheets  all  night,  exposure  of  the  body  to  cold  and  wet  when  in  a  heated 
and  perspiring  state,  are  fruitful  causes  of  attacks,  the  predisposition 
already  existing.  The  frequency  with  which  rheumatic  attacks  follow 
exposure  to  cold,  to  chilling  the  superficies  of  the  body,  is  a  very  strik- 
ing fact.  Senator  f  ingeniously  supposes  that  the  irritation  of  the 
peripheral  fibers  of  the  centripetal  nerves  excites  the  vaso-motor  and 
trophic  centers  into  abnormal  activity.  Various  facts  go  to  jsrove 
that  a  condition  of  the  joints  not  unlike  rheumatism  is  brought  about 
by  certain  diseases  of  the  spinal  cord  and  injuries  of  nerves.J  As, 
during  muscular  exercise,  lactic  acid  and  the  acid  potassium  phos- 
phate are  produced,  and  as  an  excess  of  acid  is  a  fact  in  rheumatism, 
and,  further,  as  sudden  chilling  of  the  body  stops  the  elimination  of 
those  acid  products,  which  therefore    accumulate,  there  would  seem 

*  Notwithstanding  the  agency  of  a  damp  climate  in  causing  acute  rheumatism,  in  New 
Mexico,  a  remarkably  dry  climate,  this  disease  prevails  largely.  Indeed,  the  author  saw, 
in  1860,  what  might  be  regarded  as  an  epidemic. 

•j-  Ziemssen's  "  Cyclopajdia,"  vol.  xvi. 

\  "  Injuries  of  Nerves  and  their  Consequences,"  S.  Weir  Mitchell,  op.  cit. 


810  DISORDERS   OF  NUTRITION. 

to  be  a  necessary  connection  between  tbese  states.  The  agency  of  lac- 
tic acid  in  producing  rlieumatism  seems  further  strengthened  by  the 
fact,  first  observed  by  Richardson,  that  the  injection  of  lactic  acid  is 
followed  by  endocarditis,  and  its  medicinal  administration  in  diabetes 
has  in  various  instances  apparently  caused  a  rheumatic  inflammation 
of  the  joints.  This  chemical  theory,  originally  proposed  by  Prout  and 
supported  by  Richardson's  experiments,  has  received  a  severe  blow  in 
the  denial  by  Reyher  *  that  the  injection  of  lactic  acid  is  followed  by 
endocarditis,  as  affirmed  by  Richardson,  or  that  an  accumulation  of  the 
acid  in  the  blood  is  a  cause  of  rheumatism,  as  suggested  by  Prout. 

Pathological  Anatomy. — The  changes  in  the  joints  are  slight  as  com- 
pared with  the  apparent  extent  of  the  mischief.  The  synovial  mem- 
brane is  injected  more  or  less  deeply,  and  the  fringes  are  highly  vascu- 
lar. The  membrane  has  lost  its  pearly  transparency  and  its  smooth- 
ness, and  is  cloudy  and  granular.  The  synovial  fluid  is  increased  in 
amount  and  is  changed  in  character.  Instead  of  being  a  transparent, 
homogeneous,  viscid  fluid,  it  is  thin,  watery,  reddish  from  extravasated 
blood,  turbid  from  the  presence  of  fibrin,  and  some  pus-corpuscles. 
There  is  never  any  considerable  amount  of  blood  present  in  the  fluid, 
except  in  the  case  of  the  haemorrhagic  diathesis,  and  the  quantity  of 
pus  is  slight  unless  the  rheumatic  inflammation  is  complicated  by  some 
other  malady.  A  half -century  ago  much  importance  was  ascribed  to 
the  excess  of  fibrin  in  the  blood,  to  the  buffy-coat  and  to  the  cupped 
appearance  of  the  clot ;  but  these  features  of  the  blood  composition 
are  not  now  considered  to  have  any  special  significance,  besides  the 
excess  in  fibrin.  Garrod  states  that  the  quantity  of  fibrin  reaches  from 
four  to  six  parts  per  thousand.  The  serum  is  alkaline,  and  is  free  from 
uric  acid  and  lactic  acid.  The  usual  complication  of  acute  rheumatism 
is  inflammation  of  the  peri-  and  endocardium.  The  nature  of  the 
pathological  changes  in  these  cardiac  affections  is  set  forth  in  the 
articles  on  these  topics. 

Symptoms. — For  several  days  previous  to  the  attack  of  acute  rheu- 
matism, the  patient  complains  of  muscular  soreness,  often  of  neuralgic 
pains  localized  in  some  important  nerve  ;  in  other  cases  the  patient  ex- 
periences a  good  deal  of  pain,  stiffness  and  soreness  of  certain  joints, 
and  with  these  joint-  and  muscle-pains  and  soreness  are  associated  an 
impaired  appetite,  coated,  pasty  tongue,  constipation,  etc.  The  disease 
may  begin  abruptly  without  the  prodromic  symptoms  just  described, 
by  a  chill,  followed  by  fever,  or  by  a  succession  of  slight  chills  with 
fever,  the  temperature  rising  to  102,°  103,°  or  104°  Fahr.  There  occur 
also,  thirst,  a  coated  tongue,  anorexia,  and  constipation  ;  headache  and 
wakefulness  are  experienced  ;  and  the  ankles  become  painful  and  can 
not  support  the  body.     Examination  of  the  painful  joints  discloses  the 

*  "  Zur  Frage  von  der  Erzengung  von  Endocarditis  durch  Milchsaure-injection,"  etc., 
by  Dr.  Gustav  Ileyher,  Virchow's  "  Archiv,"  vol.  xxi,  p.  85. 


ACUTE   RHEUMATISM.  g^^ 

fact  that  they  are  tender,  hot,  swollen,  and  red,  and  every  attempted 
movement  produces  exquisite  suffering.  On  the  same  day,  or  certainly 
the  next  day,  other  joints  are  affected,  and  those  first  attacked  get  a 
little  easier  and  the  swelling  slowly  subsides.  In  the  first  attack  the 
larger  joints  are  affected  almost  entirely,  but  in  succeeding  attacks  the 
smaller  joints,  especially  of  the  hands,  suffer  severely.  The  joints  first 
attacked  and  getting  well  may  be  seized  upon  again,  and  in  turn  most 
of  the  joints  of  the  body  are  affected.  By  the  end  of  the  first  week, 
a  number  of  joints,  six,  ten,  even  twelve,  may  be  inflamed.  The 
joints  most  frequently  visited  are  the  ankle  and  knee  ;  next,  the  shoul- 
der, elbow,  and  wrist ;  then  the  hip  and  fingers,  and  finally  the  spine, 
the  toes,  and  the  lower  jaw.  Even  the  crico-arytenoid  articulation  may 
be  attacked  (Senator).  The  disease  seems  to  pursue  a  certain  order  in 
its  visits  to  the  articulations — first  touching  at  the  right  ankle-joint, 
then  flying  over  to  the  left,  then  the  right  knee  is  reached,  afterward 
the  left  (Garrod).  The  suffering  imposed  by  a  rheumatic  seizure  is  very 
great  in  any  case,  but  is  the  greater  the  larger  and  the  more  numer- 
ous the  joints  inflamed.  When  the  spine  is  attacked  the  pain  and  in- 
convenience are  at  the  maximum,  for  no  movement  of  the  body  can  be 
attempted,  and  even  breathing  is  painful.  The  position  assumed  by 
the  patient  is  the  easiest  which  his  disability  will  permit ;  the  limbs 
are  half  flexed,  the  foot  turned  in  a  little,  and  the  hand  extended,  the 
fingers  separated  more  or  less  widely.  So  exquisitely  tender  are  the 
joints,  in  many  cases,  that  the  patients  njanifest  uneasiness  when  any 
one  approaches  the  bed  ;  the  weight  of  the  bedclothes  becomes  intoler- 
able ;  and  even  the  jar  of  one  walking  heavily  over  the  floor  awakens 
j)ain.  The  joints  are  red  and  swollen,  and  sometimes  the  tendons  and 
connective  tissue  about  the  joints  are  infiltrated  and  (Edematous.  On 
the  other  hand,  the  joint  may  have  a  natural  appearance  and  yet  be 
very  painful.  Even  when  quite  a  good  deal  swollen,  the  inflammation 
may  subside  in  a  few  hours,  and  attack  other  joints  in  a  corresponding 
way. 

This  tendency  to  migrate  from  one  joint  to  another  is  the  most 
characteristic  feature  of  acute  rheumatism.  As  the  effusion  into  and 
about  the  joint  is  serous,  and  as,  besides  this,  only  a  condition  of  hypei*- 
semia  is  present,  it  is  not  surprising  that  such  sudden  transitions  take 
place.  In  the  mildest  cases,  with  few  joints  affected,  and  without 
complications,  the  fever  is  slight,  consisting  of  an  exacerbation  devel- 
oping toward  evening,  and  entire  freedom  from  any  increased  body- 
heat  the  rest  of  the  time.  In  the  decided  cases,  however,  there  is  fever 
of  a  somewhat  remittent  type,  the  exacerbation  coming  on  in  the  after- 
noon. The  maximum  rarely  exceeds  104°  Fahr.,  and  the  usual  tem- 
perature is  100°  to  101°  in  the  morning  and  from  a  half  to  one  degree 
higher  in  the  afternoon.  The  range  of  febrile  heat  is  not  uniform  ; 
besides  the  daily  variations,  remissions  and  even   intermissions  take 


812  DISORDERS   OF  NUTRITION. 

place  during  the  course  of  the  disease.  If  there  should  occur  a  com- 
plete intermission,  usually  there  is  an  exacerbation  of  all  the  symptoms 
with  the  rise  of  fever.  The  termination  of  the  febrile  movement  is 
gradual  and  not  by  crisis.  Now  and  then  a  case  of  remarkable  sever- 
ity is  encountered.  Violent  delirium  occurs  and  a  state  of  hyperpy- 
rexia comes  on,  the  temperature  rising  to  108°,  109°,  and  even  111° 
Fahr.,  has  been  noted,*  and  the  rise  continues  subsequent  to  death, 
for  a  short  time.  Dr.  Ringer  observed  that  this  condition  came  on 
suddenly  in  three  cases  who  were  doing  well.  Either  delirium  fol- 
lowed by  stupor  or  stupor  without  delirium  appeared  without  any 
warning,  the  temperature  rose  to  111°  in  one  case,  and  to  109°  and 
110°  in  the  others,  and  death  ensued  in  all  in  a  few  hours.  Quincke, 
Wilson  Fox,  and  others  have  reported  similar  cases,  but  they  are  for- 
tunately rare.  Delirium,  coma  vigil,  excitement  with  very  high  tem- 
perature, phenomena  not  unlike  one  variety  of  heat-stroke,  occur  in 
the  case  of  spirit-drinkers  or  the  cachectic  attacked  by  acute  rheuma- 
tism. The  rate  of  pulse  is  not  usually  conformable  to  the  temperature 
curve,  because  it  is  accelerated  by  other  causes — chiefly  by  the  pain. 
There  is  in  acute  rheumatism  not  a  hot  skin,  because  of  the  sweating. 
This  free  action  of  the  skin  is  a  part  of  the  morbid  process  ;  it  occurs 
with  the  joint  affection,  and  subsides  somewhat  before  the  latter,  and 
returns  with  a  relapse.  The  sweat  is  acid  in  reaction,  and  the  linen 
and  person  of  the  patient  have  a  strong  acid  odor.  The  sweat  also 
contains  urea,  and  formerly  was  supposed  to  owe  its  acidity  to  lactic 
acid — a  statement  which  has  not  been  confirmed.  As  in  other  dis- 
eases characterized  by  profuse  sweating,  sudamina  appear  on  the  skin. 
Other  eruptions  are  also  sometimes  present — urticaria,  jDurpura,  her- 
pes, etc.  The  severe  loss  by  the  skin  necessarily  lessens  the  quantity 
of  urinary  water.  The  urine  is  concentrated,  strongly  acid  in  reac- 
tion, of  a  deep-red  color,  and  deposits  a  great  quantity  of  urates  and 
uric  acid.  The  chlorides  of  the  urine  are  diminished,  the  sulphates 
are  increased  (Parkes),  and  the  urea  is  also  greater  than  normal 
in  its  relative  proportion.  Albumen  is  present  in  the  urine  in  small 
amount. 

Course,  Duration,  and  Termination.— The  course  of  acute  rheuma- 
tism is  much  influenced  by  complications.  The  most  important  com- 
plication is  the  rheumatic  inflammation  of  the  peri-  and  endocardium, 
and  of  the  cardiac  muscle.  This  sometimes  is  the  first  symptom,  the 
joint  affection  appearing  subsequently.  The  author  saw  in  New  Mex- 
ico cases  of  rheumatism  pursuing  this  course.  The  relative  propor- 
tion of  heart  cases  to  those  having  joint  lesions  only  is  stated  differ- 
ently by  different  authorities,  Bouillaud  standing  at  one  extreme  with 
fifty  per  cent.,  and  Chambers  at  the  other  with  five   to  seven   per 

*  Ringer,  Dr.  Sydney,  "  On  some  Fatal  Cases  of  Rheumatic  Fever,  accompanied  by  a 
Very  High  Temperature  of  the  Body,"  "  Medical  Times  and  Gazette,"  October  5,  186Y. 


ACUTE   RHEUMATISM.  813 

cent.*  There  can  be  no  doubt  that  great  differences  exist,  and  hence  no 
numbers  can  state  the  true  proportion.  The  inmates  of  hospitals  have  a 
greater  tendency  to  heart  complication  than  those  sick  under  favor- 
able conditions  at  home.  The  existence,  then,  of  the  various  diatheses 
and  cachexioe  must  exert  an  unfavorable  influence  over  the  course  of 
acute  rheumatism.  Again,  youth  is  a  predisposing  cause  of  cardiac 
complication,  a  fact  which  Senator  f ormularizes  as  follows  :  "  The 
younger  the  patient,  the  greater  the  risk  of  his  heart  becoming  af- 
fected." Treatment,  according  to  the  exhibit  of  Dr.  Dickinson,  exer- 
cises no  little  influence  over  the  tendency  to  cardiac  complications,  if 
rightly  directed.  Comparatively  rare  complications  are  bronchitis 
and  pneumonia — the  former  occurring  the  more  frequently.  Pleu- 
risy is  still  more  common  because  induced  by  contiguity  of  tissue,  and 
hence  of  the  left  side  chiefly,  although  it  may  be  double.  These  com- 
plicating diseases  differ  in  no  material  way  from  the  same  idiopathic 
affections.  Meningitis  has  rarely  occurred,  and  doubtless,  of  the  cases 
reported,  most  of  them  were  examples  of  cerebro-spinal  meningitis. 
The  natural  history  of  acute  rheumatism  has  been  determined  thor- 
oughly. The  mint-water  treatment  of  Sir  William  Gull  and  Dr.  Sut- 
ton, and  the  expectant  methods  of  Garrod  and  of  Flint,  have  demon- 
strated the  course  pursued  by  rheumatism  when  not  interfered  with 
by  remedies.  The  disease  manifests  a  tendency  to  spontaneous  cure 
about  the  thirteenth  to  the  fifteenth  day,  and  still  more  decidedly 
from  the  fifteenth  to  the  twenty-first  day.  The  average  stay  of  rheu- 
matic patients  in  Guy's  Hospital,  when  subjected  to  the  "  mint-water 
treatment,"  was  for  males  2T'6  days,  and  for  females  26*8  days.f  The 
conclusions  arrived  at  by  the  advocates  of  non-intervention  have  been 
severely  contested  by  Dr.  Fuller  and  others.  In  almost  the  last  paper 
written  by  the  late  Dr.  Fuller, J  he  has  demonstrated  the  fallacy  under- 
lying the  observations  of  the  Guy's  Hospital  clinicians,  and  has  proved 
the  immense  superiority  of  the  so-called  alkaline  treatment.  Notwith- 
standing the  disease  may  be  classed  with  the  self -limited,  its  course  is 
materially  abbreviated  not  only  by  the  alkaline,  but  by  other  methods 
of  treatment.  The  acute  stage  of  a  rheumatic  seizure,  if  the  first  one, 
is  not  often  terminated  in  an  earlier  period  than  two  weeks,  and  is 
more  frequently  prolonged  to  three  or  even  four  weeks.  After  the  first, 
the  subsequent  attacks  are  usually  less  severe,  and  the  acute  symptoms 
terminate  in  one  to  two  weeks,  and  may  be  prolonged  to  three.  The 
duration  is,  however,  materially  affected,  not  only  by  the  complications 

*  But  Dr.  Fuller,  in  his  "  Treatise  on  Rheumatism,"  puts  the  proportion  of  heart 
complications  at  one  third,  after  examination  of  many  statistics  (third  edition,  pp.  258- 
284). 

f  "Guy's  Hospital  Reports"  for  1865,  "Cases  of  Rheumatic  Fever,  treated  for  the 
most  part  vrith  Mint- Water,"  collected  from  Dr.  Gull's  case-books  by  Dr.  Sutton. 

X  "The  Practitioner,"  vol.  ii,  p.  129. 


814:  DISOEDEES   OF   NUTEITION. 

mentioned  above  and  by  the  treatment,  but  by  the  number  of  joints  vis 
ited.  If  more  than  six  joints  are  visited,  the  duration  of  the  acute 
symptoms  will  not  be  less  than  two  to  three  weeks  ;  and,  if  a  dozen 
joints  are  one  after  another  brought  within  the  diseased  circuit,  the 
duration  will  be  scarcely  less  than  the  traditional  six  weeks.  So  many 
factors,  therefore,  are  concerned,  that  results  must  be  very  uncer- 
tain which  are  ai-rived  at  without  estimating  the  value  of  all.  Rheu- 
matism is  by  no  means  a  serious  disease  if  judged  from  the  standpoint 
of  its  immediate  effects,  but  it  becomes  more  formidable  when  the 
cardiac  and  other  complications  arise.  The  mortality  from  rheuma- 
tism alone  does  not  exceed  three  per  cent.  ;  but  the  after-consequences 
of  the  cardiac  lesions  are  responsible  for  a  great  many  more  deaths. 
When  death  occurs  during  the  seizure,  it  is  determined  by  the  condi- 
tion of  hyperpyrexia  with  delirium  most  frequently,  and  alcoholic  ex- 
cess is  probably  the  real  cause  of  this  accident  in  most  cases.  'Now 
and  then  a  fatal  result  may  be  due  to  meningitis,  but  more  frequently 
to  peri-  and  endocarditis,  with  myocarditis.  In  a  very  small  propor- 
tion of  cases  joints  may  be  permanently  damaged  by  thickenings  and 
dejiosits,  and  slow  chronic  synovitis. 

Diagnosis. — A  well-developed  acute  rheumatism  can  hardly  be  mis- 
taken for  any  other  disease,  but  there  may  be  difficulty  in  differentiat- 
ing it  from  pyaemia,  rheumatoid  arthritis,  acute  general  gout,  urethral 
rheumatism,  and  hysterical  joint.  Pyeemia  differs  from  acute  rheuma- 
tism in  the  type  of  fever,  the  periodical  sweats,  the  jaundice,  the  pros- 
tration, and  the  suppuration  and  disorganization  of  joints.  Acute 
rheumatoid  arthritis  is  stationary,  and  is  free  from  constitutional  dis- 
turbance, from  sweats,  and  from  cardiac  lesions.  From  acute  general 
gout  it  is  distinguished  by  the  fever,  the  sweats,  and  the  cardiac  mis- 
chief. Urethral  rheumatism  attacks  one  joint,  the  ankle  or  wrist, 
most  usually,  does  not  migrate,  is  slower  to  recover,  is  unaccompanied 
by  fever,  and  is  coincident  with  a  urethral  discharge.  Hysterical  joint 
is  without  swelling  or  change  of  temperature,  is  exquisitely  sensitive 
when  the  attention  is  fixed  on  it,  and  can  be  handled  even  roughly 
when  the  attention  is  directed  to  other  objects,  and  is  accompanied 
with  other  hysterical  manifestations. 

Treatment. — Opinions  are  still  greatly  divided  as  to  the  best  treat- 
ment of  acute  rheumatism.  As  controversial  discussions  do  not  enter 
into  the  seojDe  of  this  work,  the  author  confines  himself  to  the  expres- 
sion of  his  convictions.  The  alkaline  treatment  has  been  a  real  and 
important  advance,  but  the  general  conception  of  what  is  meant  by  it 
is  singularly  cloudy.  Senator  gravely  proposes  the  use  of  the  soda- 
salts  because  of  the  supposed  toxic  effects  of  the  potash-salts  on  the 
heart.  "  By  the  alkaline  treatment,"  says  Dr.  Fuller,  "  I  mean  a  plan 
of  treatment  in  which  alkalies  play  an  important  part,  but  which  con- 
sists not  only  in  the  administration  of  alkalies,  but  in  the  careful  regu- 


ACUTE   RHEUMATISM.  815 

lation  of  the  secretions,  the  strictest  attention  to  diet,  and  the  admin- 
istration of  tonics,  such  as  quinine  and  bark,  as  soon  as  the  patient  can 
bear  them."  In  the  treatment  by  alkalies,  the  object  to  be  accom- 
plished is,  to  effect  the  alkalinization  of  the  secretions,  and  any  result 
less  than  this  will  prove  a  failure.  Fuller  gives  not  less  than  an  ounce 
and  a  half  of  the  alkaline  cai'bonates,  either  alone  or  in  combination 
with  a  vegetable  acid,  during  the  first  twenty-four  hours  of  the  treat- 
ment. Two  drachms  of  bicarbonate  of  potassium  are  given  in  a  state 
of  effervescence  by  means  of  an  ounce  of  lemon-juice,  or  a  half-drachm 
of  citric  acid,  in  four  ounces  of  water,  every  three  or  four  hours.  If 
the  bowels  are  torpid,  as  is  usual,  two  compound  cathartic  pills  are 
administered.  If  the  urine  no  longer  exhibits  an  acid  reaction  after 
twenty-four  to  thirty-six  hours,  the  quantity  of  alkali  is  diminished 
one  half.  If  the  urine  continues  alkaline  at  the  end  of  another  twenty- 
four  hours,  three  drachms  of  alkali  only  are  given  for  the  next  twenty- 
four  hours  ;  and  on  the  fourth  day,  if  the  alkalinity  of  the  urine  per- 
sists, the  form  of  the  medicine  is  changed,  and  a  tonic  is  added  to  the 
alkali,  giving  three  grains  of  quinia  with  a  half-drachm  of  potassium 
bicarbonate  three  times  a  day.  Aperients  are  given  as  required,  and 
opium  as  little  as  possible,  and  only  when  there  is  excessive  irritability. 
The  diet  is  restricted  to  milk,  beef-tea,  or  broths,  barley-water,  etc., 
and  under  no  circumstances  solid  food  until  the  tongue  is  clean  and 
convalescence  established.  The  patient  is  kept  between  sheets  rather 
cool,  and  the  heaping  up  of  extra  blankets  on  the  bed  is  not  permitted. 
We  have  been  thus  full  and  minute  in  describing  Dr.  Fuller's  method, 
from  a  conviction  of  its  great  value  in  appropriate  cases.  It  relieves 
the  pain  quite  speedily,  shortens  the  duration  and  lessens  the  violence 
of  the  disease  and  prevents  heart  complications.  The  average  dura- 
tion of  the  cases  thus  treated  is  put  by  Dr.  Fuller  at  eleven  days.  Of 
439  cases  subjected  to  this  plan  there  was  not  a  fatal  case  ;  only  a  lit- 
tle over  two  per  cent,  suffered  with  a  cardiac  complication.  Dr.  Dick- 
inson's statistics  are  not  less  striking.  Of  161  cases,  113  were  subject- 
ed to  some  other  than  alkaline  treatment,  and  in  thirty-five,  or  30'8  per 
cent.,  the  heart  became  involved  ;  while  only  one  of  forty-eight  cases 
treated  with  alkalies  so  suffered.*  In  the  pale,  feeble,  and  anaemic 
young  subjects  attacked  with  acute  rheumatism,  alkalies  are  as  a  rule 
too  depressing,  and  are  followed  by  a  tedious  and  protracted  conva- 
lescence. In  this  class  of  cases  we  possess  a  valuable  resource  in  the 
tinctura  ferri  chloridi,  first  proposed  by  Dr.  Russell  Reynolds.  This 
remedy  must  be  given  in  full  doses  well  diluted  with  water  (  3  ss.  of 
the  tincture  to  six  ounces  of  water  taken  through  a  glass  tube  every 
four  hours).  It  has  a  most  favorable  influence  over  the  progress  of 
these  cases,  and,  as  Dr.  Anstie  pointed  out,  is  very  effective  as  a  pro- 

*  London  "  Lancet,"  January  23  and  30,  and  February  6,  1879. 


816  DISORDERS   OF   NUTRITION. 

phylactic  against  the  disease  when  an  attack  is  impending.  For  the 
acute  rheumatism  succeeding  to  scarlet  fever,  to  puerperal  fever,  etc., 
it  is  especially  desirable  and  successful.  At  the  present  time  no  rem- 
edy is  so  universally  employed  in  the  treatment  of  rheumatism  as  sali- 
cylic acid  in  various  forms.  The  success  which  attends  its  use  is  on 
the  whole  remarkable.  Now  that  the  enthusiasm  which  first  followed 
its  use  in  rheumatism  has  subsided  somewhat,  a  fair  estimate  of  its 
powers  can  be  made.  As  it  causes  very  great  depression  of  the  heart, 
and  excites  irritation  of  the  stomach,  its  utility  is  much  more  limited 
than  was  at  first  supposed.  Furthermore,  although  its  action  is  very 
prompt,  relieving  the  principal  symptoms  of  the  disease  in  two  or  three 
days,  the  tendency  to  relapses  is  very  great.  In  a  recent  paper  by  Dr. 
Greenhow,*  we  find  a  most  able  exposition  of  the  effects  and  real  util- 
ity of  the  salicylates.  He  finds  with  others  that  great  immediate 
relief  follows  the  administration  of  these  remedies,  that  the  tempera- 
ture declines  and  with  it  the  pain,  but  serious  toxic  phenomena  often 
ensue,  and  relapses  occur.  Moreover,  the  drug  in  considerable  doses 
depresses  the  heart,  obliterates  the  first  sound,  and  causes  vomiting, 
tinnitus,  hallucinations,  etc.  Salicin,  salicylate  of  soda,  and  salicylic 
acid,  to  be  effective,  must  be  given  in  sufficient  quantity  to  lower  the 
temperature — a  half -drachm  of  salicylate  of  sodium  every  four  hours, 
until  the  pulse  and  temperature  decline,  may  be  taken  as  the  standard. 
When  the  pain  and  fever  subside,  the  dose  may  be  reduced  to  a  scruple. 
In  the  discussion  which  followed  the  reading  of  Dr.  Greenhow's  paper, 
the  speakers  insisted  on  the  persistent  use  of  the  remedy  to  prevent 
relapses.  As  the  effects  of  salicylic  acid  and  its  congeners  are  decided- 
ly spoliative,  the  patient  is  left  in  a  weak  and  anaemic  state.  It  is  good 
practice,  according  to  the  author's  experience,  to  give  the  muriated 
tincture  of  iron  as  soon  as  the  reduction  of  heat  and  pain  is  effected, 
while  smaller  doses  of  the  salicylates  are  continued.  Dr.  Greenhow 
finds  that  the  blister-treatment  is  quite  as  successful  as  the  treatment 
by  salicylates,  and  open  to  less  objection.  The  blister-treatment  as 
revived  by  Dr.  Davies,  of  the  London  Hospital,  consists  in  the  appli- 
cation of  armlets,  wristlets,  and  fingerlets  of  blistering-plaster  about 
the  inflamed  joint,  but  not  on  it,  as  carried  out  by  Dr.  Dechilly.  The 
author  has  ascertained  that  an  investment  of  the  joint  by  small  blis- 
ters, leaving  space  between  them  all  around  the  joint  for  succeeding 
applications,  is  a  good  method.  Blisters  relieve  the  pain  remarkably, 
change  the  reaction  of  the  urine  from  acid  to  neutral  or  alkaline,  and 
prevent  complications.  With  blisters  may  be  combined  the  excel- 
lences of  the  other  plans  of  treatment.  The  alkaline  treatment  is  par- 
ticularly applicable  to  "  the  obese,  florid,  but  flabby  drinkers  of  malt- 
liquors  "  ;  the  iron-treatment  to  the  pale,  delicate,  and  anaemic  young 
*  The  London  "Lancet,"  May  29,  1880,  "Cases  of  Rheumatic  Fever  treated  with 
Salicylate  of  Soda,"  "  Transactions  of  the  Clinical  Society." 


CHRONIC   RDEUMATISM.  817 

subject  ;  and  the  salicylic  treatment  to  the  vigorous,  able-bodied  sub- 
jects of  the  inherited  tendency  or  rheumatic  diathesis,  while  blisters  may 
be,  with  proper  precautions,  utilized  in  all  forms  of  the  disease  and  com- 
bined Avith  any  plan.  The  complications  of  acute  rheumatism  are  to 
be  treated  according  to  their  character.  The  most  important,  because 
so  rapidly  fatal,  is  the  condition  of  hyperpyrexia  with  coma.  Since  the 
remarkable  efficiency  of  the  cold  bath  has  been  ascertained,  better 
results  are  had  from  the  treatment  of  this  condition  than  ever  before. 
Quiet  and  rest  are  of  great  importance.  Solid  food  must  not  be  given 
the  patient  until  the  tongue  is  clean  and  the  digestion  active.  Milk, 
above  all  things,  is  the  most  suitable  article  of  diet. 


CHRONIC   RHEUMATISM. 

Definition. — By  chronic  rheumatism  is  meant  an  affection  of  the 
articulations,  characterized  by  pain  and  stiffness,  with  some  swelling, 
occurring  chiefly  after  middle  life,  and  influenced  by  atmospheric 
changes. 

Causes  and  Pathogeny. — The  chronic  may  succeed  to  the  acute 
form  of  rheumatism.  In  all  cases  of  the  acute  disease  the  joints 
remain  sore  and  stiff  for  a  short  period  after  the  acute  symptoms 
have  ceased ;  but  in  a  few,  owing  to  the  constitutional  state,  to  im- 
proper management,  too  early  use  of  the  joints,  etc.,  the  articulations 
remain  swollen,  more  or  less  tender,  and  disabled.  The  case  may  be 
chronic  from  the  first.  If  the  predisposition  exist,  exposure  to  cold 
and  dampness,  working  in  the  water,  etc.,  will  develop  the  disease 
slowly,  and  those  joints  undergo  alterations  first  which  are  most  ex- 
posed to  injury,  and  to  cold  and  dampness  in  the  performance  of  their 
functions.  The  changes  of  structure  are  not  well  defined  in  many 
instances,  because  of  the  fugitive  attacks  ;  in  others,  however,  there 
are  plain  evidences  of  mischief  done.  The  synovial  membrane  becomes 
cloudy,  thickened,  and  rough,  and  the  cartilages  also  undergo  prolifera- 
tion of  their  corpuscles  and  subsequent  thickening.  Very  little  effusion 
of  fluid  occurs  into  the  synovial  sac.  Fatty  degeneration  of  the  artic- 
ular cartilages,  erosions  of  the  same,  slow  changes  in  the  bone,  leading 
to  induration  and  thickening,  re  .ulting  in  a  limited  extent  of  motion 
of  the  articulation,  are  also  results  of  the  morbid  process. 

Symptoms. — The  trouble  is  limited  to  the  articulations  affected  and 
to  the  neighborhood.  The  joint  is  swollen  more  or  less,  and  its  move- 
ments are  constrained  ;  it  is  not  red  and  hot  unless  some  recent  inflam- 
matory mischief  has  been  lighted  up  ;  pain  is  felt  in  the  joint  spon- 
taneously, and  soreness  whenever  the  joint  is  moved,  and  acute  pain 
is  experienced  when  there  occur  changes  of  temperature  and  the  barom- 
eter is  falling.  Patients  soon  leani  the  indications,  afforded  by  their 
pains,  when  storms  are  imminent,  or  other  atmospheric  perturbations. 
52 


818  DISORDERS   OF  NUTRITION. 

The  joints  are  stiff,  their  movements  slow  and  jerking.  As  the  sheaths 
of  the  tendons  are  thickened  by  deposits,  movements  cause  more  or 
less  creaking,  like  rusty  machinery,  which  may  be  audible.  In  the 
morning,  on  rising,  raovements  are  particularly  slow,  rigid,  jerking,  so 
that  dressing  is  accomplished  with  difficulty  ;  use  renders  them  limber 
and  supple.  Various  joints  are  affected,  as  a  rule,  but  the  disease  does 
not  migrate  from  one  joint  to  another  ;  they  may  be  affected  simul- 
taneously or  in  turn.  The  muscular  pains,  which  usually  accompany 
the  joint  affection,  are  due  to  the  extension  of  the  disease  to  the  sheaths 
of  the  tendons  in  the  neighborhood  of  the  articulations.  Myalgia  is 
a  frequent  coincident  affection,  and  hence  it  is  confounded  with  the 
rheumatism. 

Course,  Duration,  and  Termination. — Chronic  rheumatism  is  a  very 
chronic  disease.  There  occur  but  few  changes  from  month  to  month. 
Exposure  to  cold,  and  especially  to  cold  and  dampness  combined,  in- 
creases the  pains  and  the  joint  changes  ;  and  warmth — especially  re- 
moving to  a  warm  climate — lessens  them.  Fatigue,  manual  labor, 
especially  in  cold  and  damp  situations,  and  clothing  insufficiently 
warm,  promote  the  disease.  In  forming  conclusions  as  to  the  future 
course  of  the  malady,  these  elements  must  be  taken  into  considera- 
tion. A  perfect  recovery  must  be  regarded  as  possible  only  in  those 
cases  treated  at  the  outset  under  favorable  hygienic  and  personal  con- 
ditions. When  deposits  have  taken  place,  and  the  cartilages  and  syno- 
vial membrane  are  changed  in  structure,  a  cure  can  not  be  effected.  In 
old  cases  tendinous  anchylosis  may  result,  and,  the  muscles  wasting,  the 
limb  will  appear  much  deformed.  Chronic  rheumatism  never  causes 
death,  nor  does  it  indirectly  abridge  life  except  by  depriving  the  pa- 
tient of  rest  and  sleep. 

Treatment. — The  remedies  intended  to  assail  chronic  rheumatism, 
from  the  constitutional  side,  are  numerous,  but  they  accomplish  lit- 
tle. Colchicum,  guaiacum,  conium,  etc.,  formerly  so  much  employed, 
have  no  longer  any  repute  as  remedies  in  this  disorder.  There  are, 
however,  a  few  remedies  of  real  value — cod-liver  oil,  iodide  of  potas- 
sium, muriate  of  ammonia,  and  the  lithium  salts,  notably  the  bromide. 
Cod-liver  oil  should  be  given  with  a  little  ether  to  assist  its  digestion, 
and  in  the  dose  of  a  teaspoonful  three  times  a  day  after  meals.  To 
be  of  real  service,  the  administration  of  the  oil  should  continue  for 
many  months.  If  there  is  anaemia,  chalybeates  should  be  given.  A 
course  of  iodide  of  potassium,  if  the  general  health  of  the  patient  is 
fairly  good,  often  renders  important  service.  It  is  necessary  to  give 
it  many  months,  however.  Deposits  about  joints  may  sometimes  be 
absorbed  during  the  administration  of  muriate  of  ammonia,  but,  to 
accomplish  anything,  prolonged  use  is  necessary.  In  several  cases  the 
author  has  had  excellent  results  from  the  bromide  of  lithium.  Under 
its  use  the  pains  ceased,  the  swelling  subsided,  and  the  suppleness  of 


CHROXIC  RHEUMATISM.  819 

the  joints  was  restored.  Local  applications  are  highly  important. 
Frictions  of  the  affected  parts  with  cod-liver  oil,  after  a  general  warm 
bath,  are  an  excellent  expedient.  Warm  baths,  the  Turkish  or  Russian 
baths,  with  local  douches,  are  often,  but  not  invariably,  highly  useful. 
The  method  of  friction  and  movements,  known  as  massage,  is  probably 
the  best  of  the  local  means  of  treatment.  Good  results  are  obtained 
from  the  baths  of  the  Hot  Springs  of  Arkansas,  the  warm  and  hot 
springs  of  Virginia,  the  sulphurous  waters  of  the  Licks  of  Kentucky 
and  of  Saratoga,  the  Michigan  springs,  St.  Catherine's  of  Canada,  and 
numerous  other  "resorts"  in  this  country.  Mud-baths  are  also  em- 
ployed on  a  large  scale,  for  the  relief  of  rheumatism  and  affections  of 
the  skin,  in  certain  parts  of  Germany.  In  chronic  rheumatism  excel- 
lent results  are  obtained  from  the  use  of  galvanism.  A  current  of 
large  volume  and  low  intensity  should  be  applied  to  the  affected  joints 
to  procure  absorption  of  effusions,  and  the  sympathetic  ganglia  should 
also  be  brought  within  the  circuit.  "When  galvanism  is  to  be  applied, 
the  positive  pole  should  be  placed  over  the  principal  nerve-bundles 
above,  and  the  negative  pole  brushed  over  the  joint-region.  Each 
joint  should  be  taken  up  in  turn,  and  the  applications  be  faithfully 
made,  and  the  electrical  treatment  pursued  for  a  long  time. 

GOUT— PODAGRA. 

Definition. — By  the  term  gout  is  meant  a  constitutional  malady, 
inherited,  and  characterized  by  the  occuiTence  of  paroxysms  of  severe 
pain  in  a  small  joint — the  great-toe  usually — due  to  the  presence  of 
uric  acid  in  the  blood,  and  the  deposit  of  the  urates  in  the  structures 
of  the  articulation.  Podagra  is  the  Latin  name  for  gout  in  the  foot  ; 
chiragra,  for  gout  in  the  hand  ;  and  gonagra,  for  gout  in  the  knee. 

Causes. — ^Unquestionably,  heredity  is  the  chief  etiological  factor. 
The  causes  which  rendered  the  disease  hereditary  will,  of  course,  pro- 
duce the  disease  anew  in  those  subjected  to  their  operation.  As  a 
disorder  of  the  upper  classes — of  those  having  wealth,  leisure,  and 
the  opportunity  for  indulgence  in  the  pleasures  of  the  table — gout  has 
had  a  position  of  distinction.  Sydenham  consoled  himself  for  his  suf- 
ferings from  gout  by  the  reflection  that  it  is  an  eminently  respectable 
disease,  by  which  more  rich  men  than  paupers,  more  wise  men  than 
fools,  are  afflicted.  But  this  satisfaction  is  no  longer  afforded  the  vic- 
tims of  this  malady.  Gout  is  a  result  of  lead-poisoning,  and  indul- 
gence in  the  drinking  of  beer  and  other  malt -liquors,  and  it  therefore 
occupies  a  more  humble  position  than  formerly.  Men  suffer  from  at- 
tacks of  gout  much  more  frequently  than  women,  and  this  fact  is  as 
true  of  inherited  as  of  acquired  gout.  It  is  suggested  by  Garrod 
(originally  by  Hippocrates)  that  the  catamenial  function  acts  as  a 
"  safeguard,"  because,  when  the  inherited  tendency  exists,  the  out- 


820  DISORDERS  OF  NUTRITION. 

breaks  rarely  occur  until  after  the  menopause.  The  chief  reason  of 
the  comparative  exemption  enjoyed  by  women  is  the  difference  in 
habits  ;  when  women  adopt  the  meat-eating,  and  beer-  and  wine-drink- 
ing habits  of  men,  they  suffer  the  same  consequences.  Gout  begins 
at  a  comparatively  early  age,  when  the  bodily  predisposition  and  the 
habits  of  life  favor  its  appearance.  Paroxysms  may  begin  at  fifteen, 
but  when  the  disease  is  acquired  they  are  postponed  to  thirty-five  or 
later.  The  period  of  greatest  predominance  of  the  affection  is  from 
thirty-five  to  sixty-five,  and  after  the  latter  age  it  is  less  and  less  com- 
mon. The  habits  of  the  individual  are  largely  concerned  with  the 
early  production  of  gout.  The  drinkers  of  malt-liquors  and  wines, 
especially  the  sweet  wines,  suffer  early.  It  is  the  large  consumption 
of  beer  which  develoj)s  the  gouty  condition  in  the  laboring  classes. 
The  excessive  consumption  of  animal  food,  especially  when  washed 
down  with  malt-liquors  and  wines,  is  an  influential  factor.  Garrod 
first  demonstrated  the  important  fact  that  lead-j)oisoning  manifests 
itself,  in  a  certain  proportion  of  cases, 'by  paroxysms  of  gout.  This 
statement,  at  first  received  with  incredulity,  is  now  universally  admit- 
ted.* The  explanation  is,  that  lead  greatly  lessens  the  excretion  of 
uric  acid,  and  the  proof  is  afforded  in  the  increased  quantity  of  uric 
acid  in  the  blood.  The  climate  has  an  effect  on  the  occurrence  of  the 
seizures,  winter  being  the  season  of  greatest  tendency  to  them,  and 
hence  they  are  often  avoided  by  the  timely  transfer  to  a  warm  winter 
locality. 

Pathological  Anatomy. — The  changes  in  the  joints  are  characteristic 
when  a  single  joint  has  been  affected,  and  once  only.  In  such  a  case 
a  part  of  the  head  of  the  metatarsal  bone  was  covered  with  a  white 
incrustation  after  thirteen  years  (Garrod).  The  whole  articular  sur- 
face of  the  affected  joint  attacked  is,  in  severe  cases,  covered  with  a 
whitish  deposit,  to  the  synovial  fringes.  First,  a  transparent  fluid  is 
exuded  into  the  substance  of  the  cartilage  ;  the  water  is  absorbed, 
leaving  the  white  incrustation  composed  of  bundles  of  acicular  crystals 
radiating  from  a  center.  This  material  is  urate  of  soda.  Most  of  the 
articulations  are,  in  old  and  severe  cases,  more  or  less  affected,  but  the 
tarsus  and  carpus  and  the  surfaces  of  the  metatarsal  and  metacarpal 
bones  and  some  of  the  phalanges  are  chiefly  diseased.  More  or  less 
urate  deposits  have  been  found  in  the  bone  itself.  The  presence  of 
this  material  excites  ordinary  inflammation,  and  hence  the  thickening 
and  deformity  observed  about  the  diseased  joints  are  partly  due  to  the 
products  of  inflammation,  mixed  with  the  chalk-like  accretions  of  urate 
of  soda.  The  blood  also  contains  urate  of  soda,  and  in  the  perspira- 
tion uric  acid  is  frequently  present,  and  also  is  in  excess  in  the  fluids 
transuded  into  the  pericardium  and  peritoneum.     During  the  gouty 

*  Wilks,  Dr.  Samuel,  "Guy's  Hospital  Reports,"  1869-'Y0,  p.  40. 


GOUT.  821 

paroxysm  the  blood  is  said  to  contain  an  abnormal  quantity  of  fibrin. 
The  most  important  of  the  changes  in  internal  organs  is  that  disease 
of  the  kidney  known  as  the  "gouty  kidney."  Crystals  of  urate  of 
soda  are  deposited  in  the  tubules  and  inter-tubular  tissues,  and  may  be 
seen  by  the  naked  eye  as  white  lines.  The  kidneys  are  small,  granular, 
and  fibrous.  In  the  vascular  system,  atheromatous  changes  of  the  se- 
nile type  are  precipitated  by  attacks  of  gout. 

Symptoms. — Acute  Gout. — Gout  is  not  always  manifested  by  the 
same  signs  and  symptoms  :  it  may  be  acute,  chronic,  or  irregular.  The 
paroxysm  of  acute  gout  may  or  may  not  be  preceded  by  prodromic  symp- 
toms. In  many  patients  certain  symptoms  appear  invariably,  and  an- 
nounce the  approaching  attack.  These  preliminary  symptoms  may  con- 
sist of  gasti'ic  disorder — as  headache,  nausea,  a  coated  tongue,  constipa- 
tion, a  muddy  skin,  a  yellow  conjunctiva  ;  of  nervous  disturbance — as 
restlessness,  wakefulness,  despondency,  irritability,  peevishness,  or  ex- 
hilaration, and  high  spirits,  etc. ;  or  they  may  experience  a  more  or  less 
febrile  condition,  as  shivering,  rise  of  temperature,  and  sweating.  In 
many  cases  any  indications  of  the  approaching  tempest  are  wanting. 
The  patient  is  awakened  out  of  a  sound  sleep  about  2  a.  m.,  or  be- 
tween 12  M.  and  5  a.  m.,  with  a  sense  of  uneasiness  rapidly  growing 
into  acute  pain  in  the  ball  of  the  great-toe,  if  a  recent  case.  The  part 
the  seat  of  pain  is  red,  hot,  swollen,  and  so  exquisitely  sensitive  that 
the  lightest  touch,  the  weight  of  the  bedclothing,  the  jar  of  one  walk- 
ing over  the  floor,  can  not  be  borne.  The  veins  of  the  foot  are  swollen. 
Xow  and  then  the  muscles  of  the  leg  start  with  sudden  spasms,  and  a 
hot  pain  pierces  the  joint.  No  position  gives  relief.  If  the  foot  be 
placed  on  the  floor  the  veins  swell  still  more,  the  joint  becomes  deep 
red,  almost  purple,  and  the  pain  becomes  agonizing,  so  that  the  patient 
gladly  foregoes  any  attempt  to  walk.  As  a  rule,  a  feverish  state  de- 
velops ;  some  chilliness  is  first  experienced,  then  the  temperature  rises, 
the  pulse  quickens,  there  are  thirst  and  a  coated  tongue.  The  urine 
voided  during  the  paroxysm  is  dense,  deep  red,  acid,  and  deposits  copi- 
ously the  brick-dust  sediment.  After  several  hours  of  severe  suffering, 
and  in  the  early  morning,  the  pain  abates,  the  skin  is  covered  with  a 
warm  prespiration,  and  a  general  sense  of  relief  is  experienced.  If, 
now,  the  foot  is  kept  elevated  and  at  rest,  and  all  excitement  avoided, 
the  relief  continues  through  the  day  ;  the  joint  is  less  red,  less  swollen, 
and  less  tender  ;  but  when  evening  approaches  sharp  pains  again  fly 
through  the  joint,  the  swelling  rises  again,  and  another  night  of  agony 
is  passed.  The  same  experience  may  be  repeated  for  several  days  and 
nights  longer — exacerbations  at  night,  comparative  ease  by  day.  If 
no  treatment  of  any  kind  is  instituted,  the  case  may  continue  in  this 
way  for  a  week,  for  ten  days,  even  for  two  weeks,  but  the  usual  dura- 
tion under  the  present  treatment  is  but  four  or  five  days.  When  the 
joint  and  surrounding  tissue  are  much  swollen,  the  pain  becomes  less 


822  DISOEDERS   OF   NUTRITION. 

severe  ;  but  toward  the  end  of  tlie  paroxysm  the  swelling  subsides,  the 
redness  also,  and  desquamation  of  the  epidermis  is  apt  to  take  place  in 
fine  scales,  and  sometimes  in  large  flakes.  The  swelling  veins  collapse, 
but  when  the  foot  is  first  placed  on  the  floor  they  quickly  fill,  and  the 
whole  member  feels  sore,  and  tingles,  and  is  painful  from  a  fine  prick- 
ling. The  ankle  and  foot  are  stiflf  and  awkward  for  many  days.  The 
system  is  much  dejsressed  by  an  attack  of  acute  gout,  the  body-weight 
is  lessened,  the  lines  deepen  in  the  face.  When  the  attack  is  over,  the 
ravages  committed  by  it  are  quickly  repaired,  and  a  feeling  of  well- 
being,  often  of  exhilaration,  takes  the  place  of  the  hebetude  of  mind, 
and  the  bodily  distress,  or  other  disagreeable  sensations  which  pre- 
ceded the  outbreak.  The  patient  may  continue  free  from  gouty  parox- 
ysms for  two  or  three  years,  but  he  is  usually  visited  again  in  about  a 
year.  The  same  joint  may  be  attacked  as  before,  which  is  more  fre- 
quently the  left  metatarso-phalangeal  joint  of  the  great-toe,  but  this 
seizure  may  be  concerned  with  the  right,  or  both.  A  similar  inter- 
val may  elapse  before  the  next  seizure,  when  the  inflammation  may  be 
in  the  same  joints  as  in  the  previous  paroxysms,  or  may  extend  to 
the  other  articulations  of  the  foot,  and  to  the  ankle.  In  the  further 
progress  of  the  case  other  joints  are  affected — those  of  the  upper  ex- 
tremity, the  hip,  the  knee,  etc. — and  the  attacks  come  nearer  together, 
until  ultimately  they  may  be  expected  at  any  time.  As  the  parox- 
ysms increase  in  number,  they  decline  in  severity,  but  grow  longer 
in  duration.  The  skin  does  not  recover,  but  remains  red  and  livid, 
while  the  veins  become  varicose.  Meanwhile,  the  systemic  condition 
tends  to  permanence,  and  the  general  as  well  as  local  symptoms 
persist. 

Chronic  Gout. — The  distinction  between  acute  and  chronic  gout 
consists  in  the  wider  diffusion  of  the  articular  troubles,  their  less  pro- 
nounced character,  and  the  preponderance  of  the  constitutional  state, 
in  the  latter  or  chronic  form  of  the  malady.  The  affections  of  the 
digestive  organs,  which  precede  the  paroxysms,  and  are  present  in  less 
degree  at  all  times,  consist  of  acidity,  flatulence,  pain  about  the  epi- 
gastrium and  through  the  hepatic  region,  distress  after  eating,  haemor- 
rhoids, constipation  alternating  with  diarrhoea,  a  coated  tongue,  and 
fetid  and  heavy  breath.  Some  imes  the  paroxysms  are  preceded  by 
various  nervous  symptoms — especially  by  feelings  of  depression,  irri- 
tability, twitching  of  the  muscles,  cramps  in  the  legs,  palpitation,  and 
occasionally  intermittence  of  the  heart-beat.  The  paroxysms  occur  at 
any  time,  but  they  develop  slowly,  and  there  are  less  pronounced  local 
and  general  symptoms,  and  they  do  not  have  the  critical  character, 
nor  produce  the  relief,  of  the  acute  seizures.  The  deposits  about  the 
joints  increase  with  the  duration  of  the  case  ;  and  the  joints  become 
hard,  knobby,  and  are  often  much  distorted.  These  deposits  or  tojyhi 
(chalk-stones)  form  not  only  about  the  joints  proper,  but  in  the  ten- 


GOUT.  823 

dons  and  bursa,  producing  deformity  and  seriously  impairing  the  func- 
tions of  the  articuhitions.  Among  other  places,  these  tophaceous  de- 
posits form  on  the  helix  of  the  ear. 

Course,  Duration,  and  Termination. — Gout  is  a  very  chronic  disease, 
for,  although  there  is  an  acute  gout,  this  form  is  merely  an  exacerba- 
tion of  the  chronic  disease.  The  first  paroxysms  are  separated  by 
long  intervals,  but  after  some  years  the  chronic  gout  is  established. 
This  continues  with  varying  fortunes  for  several  years.  The  compli- 
cations which  increase  the  gravity  of  the  disease  are  numerous.  The 
chalk-stones  seem  at  first  to  be  important  only  as  they  deform  joints 
and  impair  functions,  but  they  are  foreign  bodies,  excite  inflammation 
and  ulcerations  which  show  no  disposition  to  heal,  but  continue  to 
discharge,  and  if  numerous  may  wear  out  the  strength  and  cause  death 
by  exhaustion.  The  changes  in  the  kidneys  ultimately  become  highly 
influential  factors  in  the  morbid  complexus.  These  organs  separate 
less  and  less  excrementitious  matter  ;  the  urine  is  pale,  of  low  specific 
gravity,  and  contains  albumen.  The  changes  in  the  kidneys  may  be 
the  main  causes  of  the  cerebral  symptoms  which  occur  toward  the  end, 
and  of  the  cerebral  hsimorrhage  with  which  so  many  gouty  subjects 
are  carried  off.  During  the  course  of  chronic  gout,  various  troubles 
arise  in  internal  organs,  and  are  styled  gouty.  "  Gout  in  the  stomach," 
"  gout  in  the  head,"  are  popular  phrases,  which  indicate  the  general 
belief  that  gout  abandons  the  joints  to  attack  internal  organs.  This 
notion  was  also  represented  in  the  technical  phrase  "retrocedent 
gout."  That  such  a  retrocession,  or  metastasis,  does  actually  occur,  is 
no  longer  maintained.  Important  changes  of  structure  take  place  in 
internal  organs,  as  a  result  of  chronic  gout,  and  hence,  indirectly,  gout 
may  be  responsible  for  various  diseases.  "  Gouty  kidney,"  as  it  is 
called,  and  the  serious  result  of  the  change  have  been  already  re- 
ferred to.  Atheromatous  and  calcareous  degeneration  of  the  vessels 
leads  to  attacks  of  angina  pectoris  (gout  in  the  heart,  in  popular  lan- 
guage) and  to  cerebral  haemorrhage  (gout  in  the  head).  The  changes 
in  the  composition  of  the  blood,  which  belong  to  gout,  are  fruitful 
causes  of  acute  inflammations,  as  pneumonia,  pleuritis,  etc.  The 
mode  in  which  cases  of  gout  may  ultimately  terminate  is  indica- 
ted in  these  observations  on  the  changes  wrought  by  the  disease. 
When  tlie  lesions  of  chronic  gout  are  established,  we  must  take 
a  hopeless  view  of  the  situation.  When  the  disease  is  inherited,  al- 
though it  may  not  have  proceeded  far,  the  probability  of  afford- 
ing some  permanent  relief  is  less  than  in  the  acquired  disease. 
When  the  first  paroxysm  has  occurred,  the  prognosis  will  be  great- 
ly affected  by  the  disposition  of  the  patient  and  his  power  of  self- 
control. 

Diagnosis. — Errors  of  diagnosis  are  possible  only  in  the  case  of 
chronic  gout,  and  between  this  and  arthritis  deformans.     The  differ- 


824  DISORDERS    or  NUTRITION. 

entiation  may,  however,  be  readily  made.  Arthritis  deformans  occurs 
among  the  poor  and  ill-nourished — in  women  chiefly,  and  at  or  before 
middle  life.  There  are  no  paroxysms  ;  it  is  gradual  in  its  growth,  and 
affects  the  two  sides  in  a  symmetrical  manner,  and  is  not  accompanied 
by  urate-of-soda  deposits. 

Treatment.— The  treatment  of  gout  is  concerned  with  the  parox- 
ysm, with  the  chronic  form  of  the  disease,  and  with  the  intervals  be- 
tween the  paroxysms.  There  are  two  methods  of  treating  the  parox- 
ysms of  gout — the  expectant  and  the  eliminant.  By  the  expectant, 
the  patient  is  put  at  rest,  the  joint  is  wrapped  in  cotton-wool,  a  laxative 
is  administered,  and  the  diet  is  reduced  to  slops.  Under  this  method 
the  duration  of  the  attack  is  protracted,  but  the  ultimate  results  are 
better  than  if  more  active  treatment  were  pursued,  provided  the  pa- 
tient make  such  change  in  his  mode  of  life  as  may  be  necessary.  The 
suffering  is  so  great,  however,  that  the  patient  is  usually  clamorous  for 
relief,  and  hence  more  active  measures  are  necessary.  There  are  but 
two  remedies  which  exert  a  really  curative  influence  on  gout — colchi- 
cum  and  salicylic  acid.  Colchicum  has  been  used  for  many  years,  and 
has  demonstrated  its  power  to  alleviate  the  pain  and  shorten  the  dura- 
ration  of  the  acute  attacks.  The  active  principle,  colchicia,  is  prefer- 
able to  the  crude  drug.  It  may  be  given  advantageously  with  quinia, 
morphia,  and  compound  extract  of  colocynth.  The  wine  and  tincture 
may  also  be  employed.  In  the'various  prescrij)tions  for  gout,  besides 
colchicum  there  are  usually  an  alkali,  a  potash-salt,  and  a  purgative, 
colocynth.  The  object  is  to  secure  elimination  of  the  urate  of  soda  and 
prevent  its  deposition.  Salicylates  have  recently  been  employed  with 
great  success  to  relieve  the  gouty  attack.  They  may  not  be  given 
when  the  stomach  is  very  ii'ritable,  or  in  atonic  gout,  but,  in  the  usual 
acute  gout  in  a  vigorous  subject,  the  relief  afforded  is  surely  remark- 
able. If  the  stomach  is  very  irritable,  effervescing  salines — the  com- 
mon effervescing,  or  the  sedlitz-powders  if  there  be  constipation — are 
useful  by  promoting  elimination  by  the  various  organs  of  excretion. 
If  the  pain  is  very  severe,  morphia,  hypodermatically,  will  afford 
prompt  relief,  but  remedies  of  this  kind  must  be  used  sparingly  be- 
cause of  their  eft'ect  in  stopping  elimination.  Local  treatment  is  of 
doubtful  utility.  Leeches  applied  in  the  neighborhood  are  of  real 
service  if  there  is  much  swelling,  the  patient  robust,  and  the  attack 
recent.  Blisters  in  the  neighborhood  of  the  joint  are  always  safe,  are 
useful  as  regards  the  subsequent  course  of  the  case,  and  afford  much 
immediate  relief.  Besides  these  measures,  it  is  necessary  only  to  sup- 
port the  foot  at  a  considerable  elevation,  maintain  rest,  and  cover  the 
painful  joint  with  some  cotton.  Excessive  warmth  and  much  cover- 
ing are  hurtful.  A  man  who  has  suffered  an  attack  of  gout  should  ac 
once  change  his  mode  of  living.  As  to  drop  from  an  abundant  and 
rich  diet  to  a  poor  and  spare  diet  involves  much  risk,   the  change 


ARTHRITIS   DEFORJIANS.  825 

should  be  made  gradually.  The  diet  of  a  gouty  subject  should  con- 
sist chiefly  of  vegetables  and  fruit ;  he  should  take  fresh  meat  once  a 
day  ;  coffee  and  tea  should  be  given  up,  and  skimmed  milk  substituted; 
eggs  are  also  injurious,  and  all  dishes  into  which  eggs  enter ;  pastry, 
cakes,  hot  bread,  sweetmeats,  spices,  and  condiments,  are  to  be  avoid- 
ed, while  oysters,  fish,  soups,  may  be  eaten.  Next  to  careful  regula- 
tion of  the  diet,  exercise  is  most  important.  Walking,  riding,  rowing, 
but  especially  walking,  should  be  carried  out  systematically,  and,  when 
inclement  weather  prevents  exercise  without,  it  should  be  done  in-doors. 
If  no  other  mode  of  exercise  is  possible,  passive  movements,  massage, 
and  faradization  of  the  muscles,  can  be  conducted  in  bed  if  need  be. 
Cold  bathing  is  objectionable.  The  patient  should  wear  flannel,  and  mi- 
grate from  a  cold  winter  climate  to  a  warm  one  if  his  means  permit. 
Certain  kinds  of  waters  are  serviceable  :  in  this  country,  Saratoga,  es- 
pecially the  Vichy  spring,  the  alkaline  waters  of  Wisconsin,  and  of 
St.  Catharine's,  Canada,  the  Warm  Springs  of  Virginia,  and  the  Hot 
Springs  of  Arkansas  ;  abroad,  Vichy,  Carlsbad,  Wiesbaden,  Homburg, 
etc.  Elimination  may  be  maintained  by  drinking  freely  of  ordinary 
drinking-water.  Much  of  the  efiicacy  of  alkaline  waters  is  due  to  the 
quantity  of  fluid  swallowed.  Excellent  results  are  obtained  from  the 
use  of  the  lithia  salts  in  chronic  gout.  These  preparations  promote  the 
excretion  of  uric  acid,  and  apparently  the  solution  of  the  deposited 
urate  of  soda.  The  interval  between  the  attacks  is  lengthened,  and 
the  attacks  are  less  violent  and  of  shorter  duration,  when  the  citrate  of 
lithia  has  been  given  for  some  time.  In  atonic  gout  a  modified  course 
must  be  pursued.  With  the  potash  and  lithia  salts  must  be  combined 
quinine  and  iron  ;  the  food  must  be  nourishing  without  being  abnor- 
mally stimulating,  and  massage  and  f aradism  perform  the  part  of  active 
exercise. 

ARTHRITIS   DEFORMANS. 

Definition. — By  arthritis  deformans  is  meant  a  chronic  inflam- 
mation of  the  joints,  without  fever  and  without  suppuration,  pro- 
gressive, and  causing  nearly  symmetrical  enlargement  and  deformi- 
ty of  various  articulations.  It  is  called  rheumatoid  arthritis  by 
Garrod,  and  rheumatic  arthritis  and  rheumatic  gout  by  various 
authors.  As  the  supposed  rheumatic  character  of  the  disease  is 
more  than  doubtful,  the  term  employed  by  the  German  writers — 
arthritis  deformans  —  is  preferable,  because  no  theory  is  coupled 
with  it. 

Causes. — Arthritis  deformans  does  not  appear  to  be  propagated  by 
hereditary  tendency.  It  is  more  especially  a  disease  of  women  than 
of  men,  and  is  apparently  associated  with  disorders  of  the  menstrual 
function,  particularly  at  the  climacteric  period.  Cases  do  occur  among 
men,  and  sometimes  they  are  exceptionally  severe.     Poverty  and  bad 


826  DISORDERS   OF  NUTRITION. 

hygiene,  exposure  and  hard  work,  with  inadequate  food,  prolonged 
lactation  and  frequent  pregnancies,  are  among  the  most  influential 
causes.  Garrod  holds  that  it  may  have  its  origin  in  the  tubercu- 
lar diathesis.  It  is  usually  regarded  as  a  disease  of  advanced  life, 
but  cases  occur  from  the  period  of  puberty  on.  Moral  causes  are  very 
influential  in  its  production — for  the  disease  has  repeatedly  followed 
grief,  anxiety,  and  moral  depression.  As  various  changes  in  the  joints 
are  produced  by  certain  troubles  of  the  spinal  cord,  a  state  of  the 
nerve-centers  is  invoked  to  account  for  this  disease.  Joints  that  are 
injured,  as  the  ball  of  the  great-toe  by  a  tight  shoe,  are  the  first  to 
undergo  the  change. 

Pathological  Anatomy. — At  an  early  period  there  are  seen  only  the 
changes  of  inflammation — hypersemia  of  the  synovial  membrane  and 
an  increased  amount  of  fluid  in  the  joint.  After  absorption  of  fluid 
has  occurred,  the  capsule  of  the  joint  is  found  to  be  thickened,  and 
the  ligaments  are  elongated,  thus  i^ermitting  ready  dislocation.  The 
cartilages  are  absorbed,  and  the  bones  rubbing  together  are  polished 
and  hard,  like  ivory,  a  condition  which  is  called  "  eburnation."  The 
articular  extremities  become  thickened  and  broader,  and  are  flattened 
out,  their  margins  projecting,  and  studded  with  irregularly  rounded 
bony  outgrowths.  The  fluid  contents  of  the  affected  joints  consist 
of  a  much  altered  synovial  fluid,  especially  rich  in  mucin,  and  con- 
taining cholesterin  and  lecithin  (Hoppe-Seyler  *).  In  occasional  cases 
the  capsule  of  the  joint  is  partly  or  wholly  ossified.  Not  only  the 
joints,  but  the  adjacent  tendons  and  their  sheaths  and  the  bursse, 
become  ossified,  and  the  muscles  waste  and  undergo  fatty  degen- 
eration. 

Symptoms. — Slow  enlargement  of  a  joint  that  is  exposed  to  injury, 
as  the  wrist  in  a  laundress,  the  thimble-finger  in  a  seamstress,  or,  after 
a  more  or  less  prolonged  period  of  trouble  and  anxiety,  the  general 
health  being  reduced  by  nursing,  the  knee  or  some  other  joint  becomes 
painful  and  swells.  The  first  attempt  may  subside,  and  presently  the 
same  joint  or  another  may  undergo  the  same  process,  but  a  subsidence 
no  longer  takes  place,  and  the  joint  remains  swollen.  In  a  short  time 
other  joints  are  attacked.  In  other  cases  the  first  symptom  experi- 
enced is  pain  in  the  articulations,  which  subsequently  become  swollen. 
The  joint  is  sensitive  to  atmospherical  changes,  and  feels  sore  when 
flexed  or  extended.  Acute  pains  extend  along  the  nerves  in  the  neigh- 
borhood. Thus,  if  the  changes  have  begun  in  the  hip,  the  pain  is  felt 
in  the  sciatic  nerve.  After  the  pain  has  continued  for  some  time,  the 
joints  are  observed  to  be  enlarging.  The  fingers  and  toes,  knees  and 
wrists,  are  affected  in  the  more  youthful  subjects,  while,  in  the  seriile, 
the  hips,  spine,  and  shoulders  are  more  especially  visited.     When  the 

*  Virchow's  "  Archiv,"  Band  Iv,  s.  253. 


ARTHRITIS  DEFORMANS.  827 

deposits  about  the  joints  have  attained  a  certain  magnitude,  their 
mobility  is  lessened.  After  a  more  or  less  prolonged  rest  the  parts 
become  rigid,  and  motion  is  difficult  until  the  persistent  use  of  the 
m.embers  limbers  them  again.  The  osseous  deposits  about  the  joints 
and  tendons  at  length  reach  such  a  stage  of  development  that  the 
affected  joints  have  a  very  limited  range  of  movement.  The  thick- 
ened joints  are  not  red,  but  pale,  and,  although  painful,  are  not  tender. 
The  changes  in  the  articulating  surfaces  and  the  relaxation  of  the 
tendons  lead  to  subluxations.  "When  the  articular  cartilages  are  re- 
moved, and  the  ends  of  the  bones  rub  together,  a  grating  is  produced 
that  is  felt  by  the  patient  and  through  the  soft  parts.  This  crepitant 
sound  may  also  be  due  to  the  movements  of  the  tendons  through 
their  partially  ossified  sheaths,  or  by  the  collision  of  the  osseous 
masses  which  form  about  the  various  articulations.  The  hands  are 
peculiarly  prone  to  take  on  this  deformity.  The  heads  of  the  meta- 
carpal bones  and  the  phalanges  are  distorted  by  large  nodules.  "  The 
metacai'po-phalangeal  articulations  of  the  fingers  are  flexed,  the  first 
phalangeal  extended,  causing  the  second  phalanx  to  be  thrown  back- 
ward, and  the  second  phalangeal  joint  is  also  flexed.  The  phalangeal 
joint  of  the  thumb  is  usually  extended  or  bent  backward"  (Garrod). 
When  the  larger  joints  of  the  lower  extremities  are  affected,  especially 
the  hip,  the  gait  has  a  characteristic  halt  and  limp.  The  spread  of  the 
arthritis  through  the  articulations  is  symmetrical,  or  nearly  so,*  The 
muscles  of  the  limbs  waste,  the  subcutaneous  fat  disappears,  and  hence 
the  members  have  a  wasted  appearance,  which  recalls  the  myopathies 
of  spinal  origin.  When  the  vertebrae  are  affected,  anchylosis  takes 
place,  reducing  the  flexible  spinal  column  to  the  rigidity  of  an  iron 
bar.  Various  ill  results  follow.  If  the  cer\'ical  vertebra  are  anchy- 
losed,  the  patient's  head  is  kept  erect  and  rigid  without  power  of  bend- 
ing or  turning  ;  if  the  dorsal  and  lumbar  vertebrae  are  anchylosed,  the 
body  is  twisted  and  immovable.  In  the  worst  cases,  finally,  all  the 
joints  are  spoiled,  are  fixed  in  bony  anchylosis,  and  motion  is  no  longer 
possible. 

Course,  Duration,  and  Termination.— Arthritis  deformans  is  one  of 
the  most  chronic  of  diseases,  continuing  on  its  course  for  ten,  twenty, 
even  thirty  years,  or  longer.  It  is  a  progressive  disease,  and  does  not 
cease  or  get  well  spontaneously,  yet  it  sometimes  remains  stationary 
for  months  and  years  at  a  tune.  Although  of  itself  not  affecting  the 
constitution  in  a  marked  way,  and  sometimes  not  at  all  impairing  the 
general  health,  in  other  cases  life  is  rendered  intolerable  and  the 
strength  is  exhausted  by  suffering  and  loss  of  sleep.  Most  obstinate 
sciatica  may  attend  on  the  disease  in  the  hip,  and  neuralgia,  contrac- 
tures, paralyses,  etc.,  may  be  caused  by  the  osseous  deposits  along  the 

*  Hutchison,  "Transactions  of  the  Pathological  Society,"  vol.  xxiii,  p.  19-t. 


828  DISORDERS   OF  NUTRITION. 

spine.     Otherwise  the  disease  continues  through  life,  not  apparently- 
abridging  it. 

Treatment. — The  only  remedies  which  have  appeared  to  do  any- 
good  are  iodine  and  galvanism.  The  compound  solution  is  an  eligible 
form,  which  we  may  give  in  the  dose  of  five  minims,  three  times  a  day. 
Iodine-ointment  may  be  carefully  rubbed  into  the  affected  joints. 
The  oleate  of  mercury  and  morphia  may  also  be  painted  over  (not 
rubbed  in)  the  joint,  and  along  the  course  of  painful  nerves.  Galvanic 
currents  should  be  transmitted  through  the  cervical  sympathetic,  and  be 
applied  also  to  the  affected  parts,  the  princij^al  nerve-trunks  being  in- 
cluded in  the  circuit.  As  many  as  forty  to  sixty  cups  should  be  used, 
and  large,  well-moistened  sponge  electrodes  should  be  applied.  Warm 
baths,  massage,  passive  motion,  and  faradization  of  the  muscles,  are 
among  the  very  useful  expedients  to  be  employed  in  these  cases.  Un- 
doubtedly good  results  have  been  obtained  from  the  use  of  arsenic,  if 
given  early  in  the  disease.  If  anaemia  exist,  as  is  so  often  the  case, 
iron  is  necessary.  If  the  nutrition  is  low,  cod-liver  oil  and  the  hypo- 
phosphites  may  be  given  with  advantage. 

DIABETES  MELLITUS. 

Definition.-^ 2>^a5e^es  is  a  chronic  disease  characterized  by  the 
constant  presence  of  grape-sugar  in  the  urine,  by  an  increased  urinary 
discharge,  and  by  progressive  wasting  of  the  body.  The  occasional 
and  temporary  presence  of  sugar  in  the  urine  does  not  constitute  dia- 
betes mellitus,  although  it  may  precede  the  fully  developed  disease. 
Diabetes  i?isi2ndus  is  a  malady  in  which  the  urinary  water  is  largely 
increased  in  amount. 

Causes. — Climate  exerts  a  certain  influence  in  the  causation  of  diabe- 
tes, but  the  influence  is  capricious  and  there  are  no  obvious  reasons  for 
the  greater  prevalence  of  this  disease  in  one  locality  than  in  another. 
Race  seems,  in  respect  to  one  people  at  least,  to  be  concerned — the 
Jews,  who  are  apparently  more  frequently  the  victims  of  diabetes  than 
the  Christians.  It  is  distinctly  hereditary,  and,  although  this  fact  has 
not  been  properly  appreciated  heretofore,  the  examples  of  hereditary 
transmission  are  becoming  so  numerous  that  this  will  hereafter  occupy 
a  high  position  in  the  etiology  of  the  disease  (Senator).  Diabetes  is 
more  common  in  males — three  to  one,  according  to  Brunton,*  who  bases 
his  statement  on  the  statistics  of  eight  German  and  French  authors. 
But  this  proportion  does  not  hold  good  for  children,  with  whom  fe- 
males are  more  given  to  the  disease  (Durand-Fardel,  Sen£.,cor),  and  this 
is  the  experience  of  the  author.  Diabetes  occurs  at  all  ages,  but  is 
most   frequent   in  middle   life— from  thirty  to  forty  for  males,  and 

*  Reynolds's  "  System  of  Medicine,"  article  "  Diabetes." 


DLUJETES.  829 

from  twenty  to  thirty  for  females.  There  are  two  types  of  subjects 
addicted  to  the  disease,  the  obese  and  the  thin,  and  they  represent  two 
kinds  of  causes.  The  obese  are  addicted  to  the  pleasures  of  the  table, 
suffer  from  a  certain  kind  of  indigestion,  and  are  given  to  sedentary 
habits.  In  the  thin  and  nervous  subject  the  disease  comes  on  after 
some  excitement,  chagrin,  business  failure,  or  other  cause  of  cerebral 
disturbance.  Among  the  exciting  causes  must  be  placed  mechanical 
shock,  concussion  of  the  whole  body,  or  of  the  brain  and  spinal  cord, 
blows  upon  the  hepatic  and  renal  regions,  etc.  Mental  shocks,  pro- 
found moral  impressions,  especially  anxiety  and  chagrin,  are,  in  the 
author's  experience,  very  common  causes  in  the  class  of  subjects  men- 
tioned above  ;  but,  in  the  obese  class,  errors  of  diet,  the  consumption  of 
a  large  proportion  of  farinaceous  food  and  of  malt-liquors  are  chiefly 
responsible.  The  occurrence  of  acid  indigestion  and  the  probable  for- 
mation of  lactic  acid  in  the  intestinal  canal  (the  duodenum)  are  ele- 
ments to  be  considered  in  this  connection.  To  these  exciting  causes 
must  be  added  exposure  to  cold  and  wet  while  the  body  is  heated,  sex- 
ual excesses,  extreme  fatigue,  etc. 

Pathological  Anatomy. — There  are  two  groups  of  morbid  altera- 
tions :  those  which  stand  in  an  apparently  causative  relation  to  the 
disease  ;  those  induced  by  it.  In  the  intestinal  canal  the  changes  con- 
sist in  a  proliferation  of  the  epithelial  layer  of  the  mucosa  throughout 
the  whole  tract,  in  hypersemia  and  thickening  of  the  mucous  membrane, 
and  also  sometimes  of  the  muscular  layer.  The  muscular  tissue  of  the 
heart  is  relaxed  and  fatty,  and  the  vessels,  especially  the  median  and 
small -sized  vessels,  are  atheromatous,  the  atheroma  being  more  decided 
in  the  cerebral  vessels  at  the  base  than  elsewhere  in  the  body.  The 
blood  is  altered  by  a  great  increase  in  the  amount  of  fat  in  the  serum, 
which  may  even  have  a  milky  appearance  from  this  cause.  Atrophy, 
cystic  degeneration,  and,  according  to  some,  hypertrophy  of  the  pan- 
creas, have  been  observed,  but  atrophy  occufs  in  one  half  of  the  cases 
— a  fact  of  great  pathological  importance.  More  significant  changes 
occur  in  the  liver,  but  these  are  by  no  means  constant,  for  the  liver  has 
sometimes  appeared  to  be  quite  normal.  In  twenty-seven  cases  exam- 
ined by  Dickinson  the  liver  was  healthy  in  six.  In  Seegen's  cas^ 
at  the  Vienna  Hospital,  thirty  in  number,  fifteen  presented  obvious 
changes  in  the  liver.  In  some  cases  which  have  been  reported,  the 
liver  was  enormously  enlarged.  The  most  constant  changes  consist  in 
an  active  hypersemia,  generally  diffused,  the  acini  appearing  as  well- 
defined  rose-colored  spots  surrounded  by  distended  capillaries  ;  in  en- 
largement of  the  hepatic  cells  with  rounding  of  their  contour,  and 
occasionally  in  hypertrophic  enlargement  of  the  connective  tissue  of 
the  organ.  The  kidneys  are  in  an  obvious  pathological  condition  in 
more  than  one  half  of  the  cases — usually  enlarged  and  decidedly  hy- 
pertemic,  without  being  otherwise  altered.     More  or  less  fatty  change 


830  DISORDERS  OF   NUTRITION. 

ensues  in  some  instances,  the  infiltration  of  fat  occurring  in  the  corti- 
cal portion  chiefly,  giving  to  it  a  pale-yellowish  appearance,  and  in- 
creasing its  thickness.  This  fatty  infiltration  is  no  doubt  due  to  the 
persistent  hypersemia.  Various  morbid  changes  have  been  discovered 
in  the  brain  and  spinal  cord,  but  they  are  by  no  means  uniform  in  po- 
sition or  character.  Hyperaemia,  dilatation  of  the  perivascular  lymph- 
spaces,  remains  of  old  extravasations,  pigmentations,  fatty  degenera- 
tion of  cells,  tumors,  etc.,  have  been  found  in  various  parts  of  the  brain, 
cord,  medulla,  pons,  etc.  Important  lesions,  also,  have  been  made  out 
in  the  semi-lunar  ganglion,  solar  plexus,  and  splanchnic  nerves  ;  they 
have  been  seen  much  enlarged,  thickened,  and  of  almost  cartilaginous 
hardness.  These  changes  appear  to  be  the  cause  of  the  extraordinary 
wasting  of  the  pancreas  which  so  often  takes  place.  The  lungs  are  fre- 
quently far  advanced  in  phthisis.  In  only  two  of  twenty-seven  diabetics 
under  the  observation  of  Dr.  Dickinson  were  the  lungs  free  from  the 
various  alterations  of  phthisis  at  some  stage  of  its  development.  The 
body  at  death  is  extremely  emaciated.  Remains  of  ulcers,  abscesses, 
and  gangrene  sloughs  are  to  be  seen  in  the  skin  of  various  parts.  The 
muscular  tissue  is  dry,  ansemic,  relaxed,  and  its  color  pale,  but  it  is 
sometimes  of  a  reddish-brown. 

Symptoms. — There  are  two  distinct  types  of  subjects  who  are 
aifected  by  diabetes  :  the  obese  and  phlegmatic  ;  the  thin  and  nervous. 
The  onset  and  the  behavior  of  these  two  varieties  are  very  different. 
A  recognition  of  the  peculiarities  of  each  is  necessary  to  a  proper  com- 
prehension- of  the  malady.  In  the  obese  subjects  the  onset  of  the 
disease  is  gradual ;  they  experience,  for  a  long  time  previous  to  the 
beginning  of  the  malady,  disorders  of  digestion  ;  they  suffer  from  acid- 
ity, pyrosis,  and  a  sense  of  epigastric  weight  and  uneasiness.  Not- 
withstanding the  obvious  derangement  of  the  digestion,  they  have  a 
keen,  almost  an  insatiable  appetite,  and  a  strong  thirst,  and  they  con- 
stantly increase  in  weight  up  to  a  certain  •  point.  They  pass,  at  this 
period,  an  excessive  amount  of  water,  and  the  urine  occasionally  con- 
tains sugar,  but  not  constantly  by  any  means.  They  are  troubled 
with  boils  or  carbuncles,  and  often  have  hard,  inflammatory  swellings, 
^hich  slowly  suppurate,  and  discharge  with  a  considerable  slough, 
leaving  an  indolent  ulcer  behind  which  shows  but  little  tendency  to 
heal.  In  the  thin,  nervous  type,  the  opposite  conditions  obtain.  These 
subjects  are  nervous,  suffer  from  attacks  of  neuralgia,  and  are  rather 
hypochondriacal.  With  them,  digestion  is  never  active  ;  they  are 
rather  constipated,  and  the  functions  of  the  gastro-intestinal  canal  are 
as  a  rule  performed  with  a  certain  feebleness,  withou::;  there  being  any 
pronounced  derangement.  The  disease  usually  comes  on  abruptly. 
There  may  have  been  headache,  neuralgia,  or  mental  despondency,  but 
these  symptoms  have  no  necessary  connection  with  diabetes.  After 
some  business  troubles,  anxiety,  grief,  or  other  moral  cause,  it  is  ob- 


DIABETES.  831 

served  that  there  is  an  unusual  urinary  discharge,  that  the  strength  is 
exhausted  by  the  least  effort,  and  that  a  sense  of  fatigue  is  constant. 
When  the  disease  has  really  begun,  there  are  present  constant  thirst, 
dryness  of  the  mouth  and  tongue,  an  unusual  appetite,  and  frequent 
discharge  of  urine,  in  large  amount  at  a  time.  In  other  cases  the 
vision  is  impaired,  and  the  diagnosis  is  made  by  the  oculist,  to  whom 
the  patient  has  repaired  for  advice  about  his  eyes.  The  thirst  is  ex- 
cessive, and  the  amount  of  water  and  of  other  fluids  drunk  is  enor- 
mous ;  the  appetite  becomes  voracious,  insatiable,  and  the  individual, 
who  previously  had  been  rather  indifferent  to  food,  now  gloats  over 
the  viands  placed  before  him,  and  thinks  only  of  satisfying  his  ap- 
petite. A  frequent  desire  to  micturate  comes  on  with  the  thirst,  the 
patient  is  disturbed  repeatedly  at  night,  and  in  the  morning  the  vessel 
contains  a  much  larger  quantity  than  usual.  The  aggregate  amount 
passed  in  twenty-four  hours  may  reach  80  to  100  ounces  or  more  ; 
it  is  acid  in  reaction,  and  has  a  specific  gravity  of  1020  to  1040,  even 
10.50.  The  bowels  are  confined,  the  fseces  hard,  and  voided  with  diffi- 
culty. The  saliva  is  acid.  The  tongue  is  pasty,  deeply  fissui-ed,  some- 
times blackish,  dry,  and  hard.  The  gums  may  be  soft  and  spongy, 
the  teeth  loose  and  apparently  elongated,  because  of  the  retraction  of 
the  gums.  The  breath  has  a  peculiar  mawkish,  disagreeable  odor, 
likened  to  that  of  new  hay  or  of  new  apples.  The  skin  becomes  dry 
and  rough  and  is  attacked  by  herpes  or  eczema,  and,  when  emaciation 
proceeds  to  a  considerable  extent,  is  wrinkled  and  inelastic.  The  eye- 
lids may  be  swollen.  In  one  of  the  author's  cases,  ptosis  appeared 
with  the  first  symptoms.  Headache,  vertigo,  double  vision,  neuralgia, 
wakefulness,  deep  dejection  of  mind,  abnoi'mal  sensations  in  the  skin, 
formication,  are  nervous  symptoms,  especially  apt  to  occur  in  the  thin, 
nervous  type  of  subjects.  The  sexual  ap2Detite  early  declines,  and  is 
soon  wholly  absent,  the  erections  ceasing  ^permanently.  Itching  at  the 
orifice  of  the  urethra  is  an  early  symptom  in  both  sexes,  but  especially 
in  women.  The  itching  may  extend  from  the  meatus  to  the  vulva 
generally,  and  produce  intolerable  torment.  TVTienever  this  symptom 
occurs  in  obese  women,  the  urine  should  always  be  examined.  The 
prepuce  and  the  vulva,  also,  are  excoriated  by  the  passage  of  the 
saccharine  urine  so  frequently.  Such  are  the  symptoms  of  the  dis- 
ease in  its  process  of  development.  It  is  necessary  now  to  indicate 
with  somewhat  more  detail  the  chief  features  of  the  malady  at  its 
maximum. 

The  remarkable  increase  in  the  urinary  discharge  is  the  most  strik- 
ing phenomenon.  We  have  already  mentioned  eighty  and  one  hun- 
dred ounces  as  a  not  unusual  quantity,  but  these  figures  have  been 
largely  exceeded  in  some  cases,  e.  g.,  Bence  Jones,  who  reports  a  case 
passing  seven  gallons.  On  the  other  hand,  the  urine  may  not  be  in- 
creased  above  the  normal,  or  may  fall  below  it.     Toward  the  end 


832  DISORDERS   OF   NUTRITION. 

there  may  be  a  notable  decline  in  the  quantity  of  urine,  and  this  fatal 
symptom  may  be  entirely  misconceived.  The  amount  of  urine  dis- 
charo-ed  stands  in  a  nearly  constant  ratio  to  the  amount  of  water  drunk. 
The  apparent  exceptions  to  this  are  cases  of  patients  unable  to  swallow 
much  fluid,  the  surplus  over  that  taken  into  the  body  being  formed  by 
the  oxidation  of  the  hydrogen,  or  supplied  from  the  water  stored  up  in 
the  tissues.  The  urine  of  diabetes  is  clear,  of  a  faint  greenish  tinge, 
and  is  free  from  sediment.  If  it  stand  for  some  time  in  a  warm  place, 
it  is  covered  with  the  Torula  cerevisice,  or  yeast-fungus.  The  urine  is 
acid  in  reaction.  The  specific  gravity,  as  already  stated,  ranges  from 
1020  to  1050,  but  it  may  contain  sugar,  and  yet  fall  below  normal. 
The  variety  of  sugar  present  in  the  urine  is  grape-sugar  and  not  cane- 
sugar,  the  variety  in  domestic  use.  The  former  differs  from  the  latter 
in  the  readiness  with  which  it  ferments,  in  turning  the  plane  of  polar- 
ized light  to  the  right,  and  in  its  source,  the  grape-sugar  of  commerce 
being  obtained  from  starch  by  the  action  of  sulphuric  acid.  Grape- 
suo-ar  is  also  less  sweet  than  cane-sugar,  and  is  harder  in  texture.  The 
actual  amount  of  grape-sugar  present  in  urine  ranges  from  a  mere  trace 
to  ten,  even  fourteen  per  cent.  Dickinson  reports  an  extraordinary 
case  of  a  man  who  excreted  in  twenty-four  hours  fifty  ounces  of  sugar. 
The  quantity  of  sugar  stands  in  a  certain  ratio  to  the  amount  of  urine 
— the  larger  the  fiow  of  urine  the  greater  the  quantity  of  sugar  voided  ; 
and  to  the  character  of  the  food,  for  the  more  sugar  and  starch  in  the 
food  the  more  sugar  in  the  urine.  The  high  specific  gravity  of  the 
urine  is  not  wholly  due  to  the  presence  of  sugar,  but  is  also  influenced 
by  the  quantity  of  urea,  which  may  rise  to  a  proportion  two  or  three 
times  greater  than  the  normal.  This  increase  of  urea  is  due  to  the 
largely  increased  consumption  of  nitrogenous  diet,  and  to  the  greater 
metamor])hosis  of  the  nitrogenous  tissues.  As  the  formation  of  urea 
is  one  of  the  hepatic  functions,  the  increased  production  of  this  sub- 
stance may  be  due  to  the  heightened  functional  activity  of  the  liver. 
Albumen  is  present  in  a  proportion  of  cases  not  definitely  settled.  It 
may  be  due  to  the  increased  blood-pressure.  Irritation  of  a  spot  on 
the  floor  of  the  fourth  ventricle  causes  albumen  to  appear  in  the  urine, 
as  irritation  of  another  spot  below  causes  an  excretion  of  sugar.  Ino- 
site,  or  muscle-sugar,  has  taken  the  place  of  grape-sugar  in  some  rare 
cases.  Acet07ie  has  also  appeared  in  the  urine  in  a  few  cases.  Vari- 
ous affections  of  the  special  senses  occur  during  the  course  of  diabetes. 
Ptosis  has  been  mentioned.  Amblyopia,  paralyses  of  accommodation, 
and  amaurosis,  also  occur.  The  most  striking  phenomenon  connected 
with  vision  is  the  occurrence  of  cataract,  which  is  encountered  in  the 
proportion  of  one  in  twelve  to  one  in  forty-five  cases.  The  cataract 
is  of  the  soft  variety,  and  both  eyes  are  usually  attacked,  that  in  the 
right  eye  developing  more  rapidly.  The  formation  of  cataract  is  sim- 
ply a  failure  of  the  nutrition  of  the  lens  in  consequence  of  the  state 


DIABETES.  833 

of  the  blood.  Owing  to  the  same  cause,  boils  and  carbuncles  appear 
among  the  prodi'omic  symptoms  and  also  at  the  maximum  of  the  dis- 
ease. Carbuncles  may  indeed  be  the  cause  of  death.  Gangrene  of 
the  skin,  and  gangrene  of  a  toe,  foot,  or  leg,  may  also  occur.  The 
great  loss  of  material  continually  going  on  must  necessarily  cause 
"wasting,  emaciation,  and  a  sense  of  fatigue.  A  rapid  accumulation  of 
flesh — of  adipose — takes  place  in  the  obese  subjects  of  diabetes  when 
the  disease  begins,  for  then  the  retrograde  changes  through  the  chan- 
nels of  excretion  are  not  so  active  as  the  source  of  supply.  But  pres- 
ently the  waste  exceeds  the  supply,  and  then  a  rapid  loss  of  weight  is 
observed.  Patients  going  through  this  j^rocess  present  a  very  char- 
acteristic appearance  :  they  have  an  old  look,  and  may  be  much 
wrinkled  ;  the  skin  is  rough,  cracking  at  the  ends  of  the  fingers,  and 
the  countenance  wears  an  anxious  expression.  The  lips  are  pallid,  the 
mouth  dry,  the  tongue  dry  and  hard,  and  constant  smacking  of  the 
lips  and  sucking  of  the  tongue,  in  the  vain  effort  to  moisten  the  parts, 
are  characteristic  of  diabetics.  As  the  nutritive  functions  are  so  de- 
pressed, it  is  not  surprising  that  the  temperature  of  the  body  should 
remain  below  the  normal.  It  has  been  found  as  low  as  93'2°  by  Dick- 
inson. Foster  *  has  pointed  out  the  very  curious  fact  that  the  tem- 
perature of  the  fluids  drunk  exercises  an  influence  on  the  temperature 
of  the  diabetic  patient.  His  figures  show  that,  when  all  fluids  drunk 
were  warm,  the  temperature  of  the  axilla  was  one  degree  higher  than 
when  the  fluids  were  cold. 

Course,  Duration,  and  Termination. — In  the  obese  type  the  prodromes 
may  continue  over  several  months,  even  years.  There  may  be  occa- 
sional glycosuria,  of  variable  duration,  occur  several  times,  before  the 
persistent  presence  of  sugar  constitutes  the  case  one  of  diabetes.  On 
the  other  hand,  in  the  nervous  type,  the  preliminary  symptoms  are  of 
brief  duration.  So  long  as  the  appetite  and  digestion  are  equal  to  the 
supply  of  all  the  material  excreted,  the  patient  holds  his  own.  When, 
however,  the  loss  is  in  excess,  the  decline  is  rapid.  The  cases  vary 
greatly  in  the  rate  of  progress.  Those  diabetics,  in  whom  the  proper 
regulation  of  the  diet  causes  a  disappearance  of  all  the  symptoms,  ap- 
parently recover,  and  the  duration  may  therefore  be  much  prolonged, 
but  they  ultimately  succumb,  because  they  at  length  reach  a  period 
when  they  can  no  longer  prevent  the  formation  of  sugar.  Those  cases 
proceed  rapidly  in  whom  the  changes  of  diet  make  but  little  differ- 
ence in  t*he  formation  and  excretion  of  sugar.  The  average  duration 
is  about  two  to  three  years.  Under  proper  management  favorable 
cases,  not  curable,  may  continue  for  many  years,  the  patient  mean- 
while enjoying  good  health.  Age  has  much  to  do  with  the  rate  of 
decline.      The  disease  makes  very  rapid  progress  in  children.      The 

*  "  Clinical  Medicine,"  by  B.  Foster,  M.  D.,  riiiladelphia  edition,  p.  264. 
53 


834  DISOEDERS   OF  NUTRITION. 

most  acute  cases  terminate  in  a  few  weeks.  The  jjrognosis  is  most  un- 
favorable as  regards  cure,  and  gloomv  in  respect  to  retardation.  The 
reports  of  recovery  are  discredited  by  those  of  greatest  experience. 
While  cures  may  not  be  hoped  for,  in  a  considerable  proportion  of 
cases  decided  amelioi'ation  may  be  accomplished  and  a  retardation  of 
great  length  effected  in  a  small  number.  Much  depends  on  the  influ- 
ence of  the  changed  diet  over  the  excretion  of  sugar ;  for,  if,  on  a  nitro- 
genous diet,  the  sugar  disappears  from  the  urine,  the  case  wears  a 
decidedly  more  hopeful  aspect  than  if  the  formation  of  sugar  contin- 
ues despite  the  change.  In  the  further  progress  of  the  case,  the  con- 
dition of  the  patient  will  depend  largely  on  the  behavior  of  the  diges- 
tive organs  as  confined  to  an  animal  diet.  If  he  can  not  persist  in  this 
diet,  and  his  digestive  organs  are  upset  by  the  nitrogenous  food,  a 
prompt  development  of  the  worst  symptoms  will  ensue.  The  mode  of 
dying  is  various.  Death  by  exhaustion  is  not  common.  In  some 
cases,  apparently  doing  well,  the  most  serious  symptoms,  known  as  dia- 
hetic  coma,  suddenly  appear.  Great  restlessness,  praecordial  uneasiness, 
and  pain  are  quickly  manifest ;  somnolence,  wdth  general  agitation, 
loud  cries  and  groans,  and  then  a  deej^ening  coma,  come  on,  during 
which  the  pulse  grows  weaker,  the  respirations  more  and  more  shal- 
low, the  temperature  lower  and  lower,  and  soon  the  patient  expires  in 
a  condition  of  profound  insensibility.  These  symptoms  of  such  for- 
midable character,  and  arising  suddenly,  wear  an  aspect  of  poisoning, 
very  like  that  caused  by  acetone  in  animals.  As  this  substance  may 
be  produced  in  the  blood  by  the  decomposition  of  the  diacetate  of 
ethyl — a  product  of  the  reactions  of  grape-sugar — it  is  assumed  that 
diabetic  coma  is  an  acetonemia.  The  most  frequent  cause  of  death 
is  phthisis.  This  may  develop  very  slowly  and  escape  detection  until 
far  advanced,  or  it  may  proceed  very  rapidly  and  with  pronounced 
symptoms  from  the  beginning.  Gangi-ene  of  the  lung  rarely  occurs, 
and  it  presents  the  remarkable  peculiarity  that  the  sputa  are  without 
odor. 

Diagnosis. — Diabetes  exists  only  when  sugar  is  permanently  pres- 
ent in  the  urine.  In  diabetes  insijndus  there  is  a  large  flow  of  water, 
but  no  sugar  ;  in  glycosuria  of  the  temporary  kind  sugar  is  only  occa- 
sionally present.  It  is  not  the  quantity,  but  the  persistence  of  the  sugar, 
which  constitutes  diabetes.  As  Senator  well  expresses  it,  "  a  saccha- 
rinity  of  over  ttco  per  cent,  certainly  occurs  in  diabetes,  but  a  lower 
saccharinity  does  not  exclude  diabetes."  The  iirine  of  diabetes  has 
certain  physical  peculiarities  by  which  it  may  be  recognized,  but  not 
with  the  certainty  of  chemical  reactions.  It  is  free  from  sediment, 
has  the  appearance  of  water  of  a  very  pale-greenish  tint ;  has  an  acid 
reaction,  and  a  specific  gravity  of  1025  to  1050  or  higher.  The  im- 
portance of  a  high  specific  gravity  depends  on  the  fact  that  the  quan- 
tity of  urine  is  also  large.     The  presence  of  sugar  is  the  important 


DIABETES.  835 

point,  and  this  must  be  determined  by  the  applications  of  cliemical 
tests  : 

Tromyner''s  test  is  the  most  generally  applicable.  A  few  drops  of  a 
dilute  solution  of  sulphate  of  copper  are  added  to  some  urine  in  a  test- 
tube,  or  sufficient  to  give  to  the  urine  a  blue  color,  faint  but  yet  dis- 
tinct. Then  the  same  quantity  of  liquor  potassce  as  there  is  urine  is 
added.  If  sugar  be  present,  the  precipitate  at  first  formed  is  redis- 
solved,  and  the  mixture  assumes  a  deep-blue  color.  If,  now,  heat  be 
applied,  a  yellow  or  orange-red  precipitate  of  oxide  of  copper  is  thrown 
down.  If  the  heat  be  applied  to  the  upper  part  of  the  liquid,  the  vivid 
yellow  color  of  the  oxide  of  copper  appears  bright  and  distinct  by  com- 
parison. 

JFehlingh  test  solution  must  be  kept  prepared,  and,  as  it  rapidly 
spoils  by  keeping,  frequent  renewal  of  the  solution  is  necessary.  This 
test  consists  of  a  sulphate-of-copper  solution,  mixed  with  a  solution 
of  tartrate  of  soda  and  potassa  (Rochelle  salt)  and  caustic  soda.  Some 
of  this  test  is  added  to  the  urine  in  a  test-tube  and  boiled,  the  reaction 
being  the  same  as  in  Trommer's. 

Fermentation  Test. — Some  brewer's  yeast  is  added  to  the  urine  in 
a  bottle  and  kept  at  a  proper  temperature  (60°  to  80°  Fahr.).  The 
bottle  must  be  well  corked  and  have  a  bent  tube  connected  with  it,  so 
that  the  carbonic  acid  can  be  collected  for  examination. 

Moored  test  consists  in  simply  boiling  together  equal  parts  of  urine 
and  liquor  potassce.  The  sugar  is  decomposed,  and  one  of  its  prod- 
ucts is  melassic  acid,  which  may  be  recognized  by  its  odoi-,  and 
which,  with  glucic  acid,  another  product,  converts  the  mixture  into 
a  brown,  almost  a  black  color.  The  change  of  color  is  rendered  all 
the  more  evident  by  confining  the  heat  to  the  upper  portion  of  the 
mixture. 

Treatment. — The  most  important  points  in  the  management  of  this 
disease  are  diet  and  exercise.  Medicines  are  secondary.  As  the  pres- 
ence of  sugar  in  the  blood  is  the  great  cause  of  mischief,  our  efforts 
must  be  directed  to  prevent  its  formation.  This  can  be  accomplished 
only  by  systematic  disuse  of  all  articles  of  food  convertible  into  sugar. 
Bread,  potatoes,  beans,  peas,  rice,  carrots,  turnips,  parsnips,  etc.,  and  all 
articles  containing  flour,  sugar,  or  starch,  must  be  excluded.  Greens, 
cabbage  free  of  the  stock  and  stems,  lettuce,  tomatoes,  and  spinach, 
may  be  substituted.  A  bread  made  of  powdered  almonds  and  gluten 
bread  may  also  be  substituted  for  ordinary  bread.  Milk  may  be  allowed, 
especially  buttermilk.  Donkin  reports  cures  made  by  confining  the 
patient  to  an  exclusive  diet  of  skimmed  milk — six  to  eight  pints  daily. 
Brunton  objects  to  the  skimmed  milk  because  some  die  of  inanition, 
although  he  says  others  do  recover.  All  kinds  of  flesh,  fresh  or  salt, 
fish,  including  oysters,  eggs,  gelatine,  fats,  almonds  and  nuts,  except 
chestnuts,  are  allowed  ad  lihitttm,  unless  the  too  great  consumption 


836  DISORDEES   OF  XUTRITIOK 

of  animal  food  induce  the  excessive  excretion  of  urea  and  uric  acid. 
Koumiss  may  be  taken — also  liglit  acid  wines  and  a  little  spirit  with 
meals.  Water  may  be  taken  to  satisfy  thirst,  but  a  large  quantity  of 
fluid  at  meals  must  prove  detrimental  to  digestion  and  should  not  be 
indulged  ia.  Walking  exercise  is  of  the  highest  moment.  There  is 
a  strong  sense  of  fatigue  proper  to  the  disease,  and  the  muscles  are 
actually  unequal  to  much  effort.  Surjjrising  results  may  be  accom- 
plished by  active  walking  exercise,  especially  in  the  case  of  the  obese 
diabetic.  The  strength  is  improved,  and  the  formation  and  excretion 
of  sugar  are  diminished.  The  functions  of  the  skin  should  be  maintained 
by  warm  clothing.  It  is  probable  that  pilocarpine  will  prove  beneficial 
by  increasing  the  secretion  of  the  sweat  and  saliva.  Of  the  medicinal 
remedies  but  few  have  jjroved  beneficial.  Opium,  and  especially  the 
alkaloid  codeia,*  exercises  a  great  influence  over  the  excretion  of  sugar, 
but  unfortimately  the  effect  is  not  maintaiued.  Large  doses  are  well 
borne  and  are  required.  K'ext  to  opium  is  arsenic,  which,  in  the  au- 
thor's experience,  is  highly  ser%T.ceable  in  the  obese  subjects.  It  can  be 
better  borne  if  given  with  opium  (three  drops  of  Fowler's  solution  and 
ten  drops  of  tincture  of  opium  three  times  a  day).  The  alkalies  are 
also  useful,  especially  in  the  obese.  The  author  has  met  with  an  appar- 
ent cure  by  carbonate  of  ammonia.  The  weak  alkaline  waters  of  Wis- 
consin (Bethesba),  drunk  in  large  quantities,  seem  to  exercise  a  very 
beneficial  influence.  The  Carlsbad  water  of  Germany  and  Vichy  of 
France  have  had  a  reputation  for  generations  in  the  treatment  of 
diabetes.  Saratoga  Vichy  may  be  substituted  for  the  foreign  waters. 
The  bromides  have  proved  useful  in  some  cases,  but  the  good  effects 
are  not  permanent.  The  best  results  have  been  obtained  from  the 
use  of  bromide  of  ammonium.  The  carbolate  of  iodine  (carbolic  3  j, 
tincture  of  iodine  3  ij,  given  in  the  dose  of  one  or  two  drops  well 
diluted  three  times  a  day)  has  seemed  to  have  excellent  effects  in 
some  cases,  and  therefore  deserves  more  extended  trial.  Lactic  acid 
has  proved  very  useful  in  many  cases,  and  in  the  author's  hands,  in 
the  form  of  lactophosphate  of  lime,  has  seemed  to  benefit  the  thin, 
nervous  type  of  diabetics  remarkably.  In  this  class  of  cases  the  lacto- 
phosphate of  lime  and  cod-liver  oil  have  been  even  more  advantageous. 
Lactic  acid  often  produces  rheumatism,  which  is  an  objection  to  its  use, 
and  may  require  its  suspension.  Foster  hrlds  that  the  good  effects  of 
the  skimmed-milk,  whey,  and  buttermilk  cures  are  due  to  the  formation 
of  lactic  acid  from  the  lactin  (p.  207).  Other  drugs  employed  on  theo- 
retical considerations  are  ethereal  solution  of  peroxide  of  hydrogen  and 
valerian.  Any  good  effects  derived  from  the  former  are  attributed  by 
Foster  to  the  ether.  Valerian  slightly  influences  the  excretion  of  sugar, 
but  has  a  remarkable  effect  on  the  urea,  the  excretion  of  which  lessens 

*  Pavy  especially  eulogizes  the  good  effects  of  codeia. 


DIABETES  INSIPIDUS.  837 

considerably  under  its  use.  To  these  drugs  must  yet  be  added  the 
fluid  extract  of  ergot.  This  drug  has  not  been  of  any  real  utility  in 
diabetes,  but  has  apparently  cured  cases  of  diabetes  insipidus. 


DIABETES   INSIPIDUS. 

Definition. — Diabetes  insijiidus  is  a  disease  having  for  its  chief 
clinical  feature  the  passage  of  a  very  large,  often  an  enormous,  quantity 
of  pale,  watery  m'ine,  free  from  albumen  and  from  sugar.  It  is  also 
kno^Ti  as  polyuria,  polydqysia,  eic. 

Causes. — Occasional  examples  of  hereditary  transmission  have  been 
reported.  The  disease  occurs  at  all  ages,  but  is  most  frequent  from 
twenty  to  forty-five.  Men  are  more  subject  to  the  disease  than  women. 
Among  the  exciting  causes  are  injuries  and  diseases  of  the  brain,  in- 
cluding concussion,  tumors,  exostosis,  psychical  impressions,  etc.  ;  ex- 
posure to  draughts  of  cold  air,  the  body  perspiring  freely  ;  drinking 
freely  of  cold  drinks  ;  sudden  variations  of  temperatm-e  ;  fatigue,  con- 
valescence from  fevers,  etc.  According  to  the  author's  experience,  the 
most  usual  cause  of  the  disease  is  syphiloma  of  the  brain. 

Pathological  Anatomy. — But  infrequent  opportunities  have  occurred 
for  a  study  of  the  changes  proper  to  this  disease.  Two  classes  of  le- 
sions have,  however,  been  ascertained  :  of  the  brain  and  symj)athetic 
ganglia  ;  of  the  kidneys.  In  the  brain,  changes  have  been  found  in  the 
fourth  ventricle — inflammatory  and  degenerative — tumors  in  this  re- 
gion and  in  the  cerebellum,  tubercles,  syphilitic  tumors,  etc.  Degen- 
eration of  the  solar  plexus  has  been  observed  by  Dickinson.  The 
changes  observed  in  the  kidneys  are  various — sometimes  the  organs 
are  enlarged  and  hyperaemic  ;  sometimes  the  only  change  is  dilatation 
of  the  tubules.  Other  lesions,  which  must  be  regarded  as  accidental, 
have  been  noted,  as  cancer  of  the  liver,  tumor  of  the  uterus,  and  disease 
of  the  mesenteric  glands. 

Symptoms. — It  is  rare  for  the  disease  to  begin  in  perfect  health  with- 
out any  warning.  The  rule  is,  that  the  nervous  disturbances  associated 
with  the  various  lesions  of  the  brain  occur.  In  the  author's  observa- 
tion there  were  the  usual  symptoms  of  cerebral  syphilis  preceding  the 
outbi'eak  of  polyuria.  The  large  flow  of  urine  is  the  growth  of  several 
weeks.  AVhen  the  maximum  is  attained  the  flow  is  prodigious,  but  it  is 
by  no  means  the  same  in  all  cases,  for  it  varies  from  one  to  five  gallons 
daily.  The  single  discharges  are  large,  because  the  urine  is  not  stim- 
ulating, and  can,  therefore,  be  longer  tolerated  by  the  bladder.  The 
specific  gravity  of  the  urine  is  as  low  as  1X)02,  and  does  not  go  above 
1007.  The  urine  is  pale,  usually  clear,  faintly  acid  in  reaction,  and 
readily  decomposes.  The  solid  constituents  are  somewhat  increased. 
The  excretion  of  urea  is  slightly  greater  than  that  of  a  healthy  indi- 
vidual consuming  the  same  amount   of   animal  food,  and  is  simply 


838  DISEASES  or  NUTEITION. 

due  to  the  increased  waste  of  the  nitrogenous  elements  produced 
by  the  passage  of  so  much  water  through  the  tissues.  Uric  acid 
is  diminished,  as  might  be  expected,  because  of  the  increased  for- 
mation of  urea.  The  sulphates,  phosphates,  and  chlorides,  are  also 
increased.  There  is  no  sugar  present.  The  reported  cases  of  dia- 
betes insipidus  with  albuminous  urine  were,  doubtless,  examples  of 
fibroid  kidney. 

When  there  ensues  such  a  strong  outflow  through  the  kidneys,  the 
results  of  the  loss  of  so  much  fluid  and  solid  material  are  the  same 
as  those  of  similar  fluid  discharges.  There  occur  excessive  thirst,  a 
dry  mouthj  dry  skin,  and  constipation.  The  increased  excretion  of  urea 
explains  the  diminution  of  body-weight  which  takes  place  in  this  dis- 
ease, notwithstanding  the  appetite  and  digestion  remain  at  the  normal. 
Sometimes  a  decided  lowering  of  temperature  is  observed,  but  this  may 
be  due  to  the  ingestion  of  a  large  quantity  of  cold  drinks.  Instead  of 
dryness  of  the  mouth,  there  may  be  ptyalism.  The  skin,  although  usu- 
ally dry,  as  stated,  may  be  normal,  and  there  may  be  profuse  perspi- 
rations. 

Course,  Duration,  and  Termination. — The  onset  of  the  disease  may 
be  preceded  by  the  symptoms  of  cerebral  disturbance,  due  to  the  ex- 
isting lesions  of  the  brain  and  sympathetic  ganglia.  The  increase  in 
the  flow  of  urine  and  the  consequent  thirst  may  develop  slowly,  and 
be  observed  only  when  they  are  very  pronounced.  In  still  other  cases, 
during  convalescence  from  some  acute  malady,  or  after  some  vio- 
lent mental  or  moral  shock,  or  some  severe  blow  on  or  concussion  of 
the  brain,  the  disease  begins  abruptly.  In  most  cases  the  disease  is 
rather  an  inconvenience,  owing  to  the  frequent  calls  to  micturate  and 
the  incessant  thirst,  than  a  dangerous  malady.  Death  has  resulted 
in  as  short  a  time  as  four  months,  but  here  the  fatal  result  was  due 
rather  to  associated  lesions  than  to  diabetes  insipidus.  Death  may 
result  from  the  disease,  the  continual  loss  of  material  leading  to  fatal 
exhaustion,  but  it  is  usually  due  to  some  intercurrent  disease  or  cere- 
bral lesion.  Although  death  is  rarely  due  to  the  disease,  the  prog- 
nosis is  not  favorable  as  to  cure,  unless  caused  by  syphilitic  disease 
of  the  brain. 

Diagnosis. — Those  temporary  states  in  which  a  large  quantity  of 
urine  is  voided  for  a  few  days  are  all  separated  from  diabetes  insipi- 
dus by  the  lack  of  permanence.  From  diabetes  mellitus  it  is  differ- 
entiated by  the  specific  gravity  of  the  urine  and  by  the  presence  of 
sugar.  Diabetes  insipidus  is  most  apt  to  be  confounded  with  fibroid 
kidney,  for  in  the  latter  disease  a  quantity  of  pale,  watery  urine  is 
passed,  but  it  contains  more  or  less  albumen  and  hyaline  and  waxy 
casts,  which  are  not  present  in  the  former. 

Treatment. — Several  remedies  have  been  of  real  service  ;  many 
others  of  no  value.    The  iodides  and  mercury  have  quickly  cured  cases 


nYDROPIIOBIA.  839 

of  syphilitic  origin,  Jaborandi  has  been  successful  in  Laycock's 
hands,  ei-gotin  in  those  of  Ringer  and  Da  Costa.  Valerian  has  been 
beneficial  but  not  curative  (Trousseau).  Galvanism  has  certainly  been 
of  signal  service  in  several  cases,  applied  by  one  electrode  to  the  neck 
below  the  occiput  and  the  other  to  the  hypochondi'iac  regions  in  turn. 
From  the  point  of  view  of  the  experience  thus  far  gained,  the  follow- 
ing plan  seems  most  promising  :  A  course  of  iodide  of  potassium 
should  be  at  first  administered.  The  disease  not  yielding,  galvanism 
should  be  used,  and  pilocarpine  and  ergotin  should  be  tried  succes- 
sively if  the  first  fails.  Warm  clothing  should  be  worn,  and  a  warm 
winter  climate  should  be  selected  if  practicable. 


ANIMAL   POISONS. 


HYDROPHOBIA. 


Definition. — Hydrophohia  is  a  specific  disease  due  to  the  inocu- 
lation of  a  poison  contained  in  the  saliva  of  rabid  animals,  notably 
the  dog,  and  characterized  by  pain  and  stiffness  of  the  inoculated 
part ;  by  exaltation  of  the  reflex  faculty ;  by  spasms  of  the  throat 
on  the  attempt  to  swallow,  and  subsequently  at  the  sight  of  liquids  ; 
by  delirium,  exhaustion,  and  death.  It  is  also  known  as  rabies 
canina. 

Causes. — The  sole  condition  necessary  for  the  causation  of  hydro- 
phobia is  the  inoculation  of  man  with  a  contagious  principle  contained 
in  the  saliva  of  the  dog,  cat,  wolf,  and  some  other  rabid  animals.  This 
principle  is  not  absorbed  through  the  unbroken  skin,  but  from  a  wound 
or  abrasion.  A  certain  predisposition  is  also  necessary,  it  is  probable, 
for,  of  all  bitten  by  animals  unquestionably  rabid,  but  a  small  propor- 
tion are  attacked  by  hydrophobia.  The  proportion  is  variously  stated 
from  five  to  fifty  per  cent.,  but,  while  the  former  is  much  too  small,  the 
latter  is  excessive.  Accident  more  than  predisposition  is,  however,  the 
real  cause  of  the  exemption  of  so  many  who  are  bitten.  The  teeth, 
in  inflicting  the  wound,  pass  through  clothing,  which  removes  the 
saliva,  and  hence  the  most  of  those  bitten  through  the  clothing  escape 
infection.  On  the  other  hand,  wounds  of  exposed  parts,  or  an  abrasion 
receiving  the  saliva,  is  very  certain  to  be  followed  by  the  disease,  un- 
less there  be  a  decided  insusceptibility  to  the  action  of  the  poison.  All 
ages  and  both  sexes  are  liable,  but  more  men  than  women  are  attacked, 


840  ANIMAL  POISONS. 

because  tlie  former  are  more  exposed.  Various  moral  impressions 
favor  the  occurrence  of  the  disease.  These  are  apprehension,  fear, 
excesses  of  all  kind,  fatigue,  etc. 

Pathological  Anatomy. — There  are  but  few  changes  found  post 
mortem  really  typical,  if  any  such  exist,  but  are  common  to  all  the 
diseases  of  the  same  group.  The  cadaveric  rigidity  is  well  marked ; 
there  are  extensive  suggillations,  and  putrefaction  soon  begins  ;  the 
coloring  matter  of  the  blood  stains  the  vessel-walls,  and  the  blood 
itself  is  fluid  and  has  a  violaceous  color.  These  facts  only  indicate  a 
changed  state  of  the  blood  common  to  many  maladies.  The  fauces 
are  red  and  swollen,  the  salivary  glands  enlarged  ;  the  trachea  and 
bronchi  are  hypersemic  and  contain  a  quantity  of  frothy  mucus  ;  the 
lungs  are  also  hyperaemic  and  sometimes  cedematous.  More  or  less 
congestion  of  the  brain,  effusion  into  the  ventricles,  and  hypersemia, 
with  enlargement  of  the  vessels  of  the  medulla  oblongata,  have  been 
observed.  In  some  cases  changes  of  texture,  softening,  etc.,  have  been 
seen  at  the  apparent  origins  .  of  the  seventh,  eighth,  and  ninth  nerves. 
The  pneumogastric,  phrenic,  and  sympathetic  nerves  have  also  been 
found  in  a  more  or  less  hypersemic  state. 

Symptoms. — The  period  of  incubation  is  by  no  means  confined  to 
fixed  limits.  In  214  cases  collected  by  Jaccoud,  the  period  of  incuba- 
tion was  less  than  one  month  in  one  fourth  of  the  number,  from  one  to 
three  months  in  143,  from  three  to  six  months  in  30,  and  from  six 
months  to  a  year  in  11.  According  to  Gamgee,  in  the  large  ma- 
jority of  cases,  the  period  of  incubation  is  four  to  eight  weeks.  Age 
apparently  affects  the  duration  of  this  period.  Thus  in  nine  new-born 
infants,  the  incubation  period  was  thirteen  to  fifteen  days.  A  very 
remarkable  case  has  been  reported  of  a  man  two  years  in  prison,  who 
had  hydrophobia,  and  who  had  been  bitten  seven  years  before.  During 
the  period  of  incubation  there  is  nothing  in  the  wound,  nothing  in  the 
state  of  the  organism,  to  indicate  the  existence  of  any  mischief.  The 
wound  or  abrasion  may  be  very  slight,  may  have  healed  long  since  and 
been  forgotten.  At  the  termination  of  the  incubation,  the  attention  of 
the  patient  is  attracted  to  the  wound  by  some  uneasiness  felt  in  it.  If 
it  has  not  healed,  the  wound  takes  on  a  livid  appearance,  and  becomes 
exceedingly  painful,  the  pain  shooting  toward  the  trunk  from  the  ex- 
tremities if  the  wound  is  so  situated.  If  the  wound  has  cicatrized,  the 
scar  becomes  painful,  red,  irritable,  swollen,  and  sometimes  exudes  a 
bloody  serosity.  Sometimes  a  sensation  of  coldness  and  of  numbness 
is  felt  in  the  bitten  member,  and  occasionally  the  lymphatics  of  the 
limb  are  swollen,  and  marked  by  hard,  red  lines.  The  local  symptoms 
are  soon  accompanied  by  systemic  disturbances.  The  patient  is  de- 
pressed, apprehensive,  peevish.  So  marked  is  the  condition  of  melan- 
choly that  the  first  stage  of  hydrophobia  has  been  called  the  stadium, 
m,elancholicum.    The  skin  becomes  hot,  the  pulse  rapid  and  bounding. 


HYDROPHOBIA.  841 

The  appetite  goes,  and  the  bowels  are  confined.  In  some  few  cases 
the  wound  continues  unaffected,  and  the  feelings  of  anxiety  and  alarm 
are  absent,  the  only  symptoms  coming  on  being  the  fever  and  the  gen- 
eral distress  belonging  to  the  feverish  state.  What  form  soever  this 
initial  stage  assumes,  it  is  of  short  duration,  continuing  but  a  few  hours 
or  a  day  or  two.  The  peculiar  reflex  paroxysms  then  come  on :  the 
breathing  is  sighing  and  jerking,  the  epigastrium  is  elevated  by  the 
forced  depression  of  the  diaphragm,  and  the  shoulders  are  rendered 
prominent  by  the  overaction  of  the  levator  and  trapezius,  while  at  the 
same  time  there  is  experienced  a  sensation  of  prsecordial  oppression 
and  of  tension  in  the  anterior  wall  of  the  thorax.  The  neck  grows 
stiff,  the  throat  feels  constricted,  and  the  movements  of  the  head  are  con- 
strained. iSTow  are  experienced  the  peculiar  sensations  which  are  so  dis- 
tinctive of  the  disease.  A  spasm  seizes  the  pharyngeal  muscles  when 
any  attempt  is  made  to  swallow.  The  patient  has  an  intense  thirst,  but 
whenever  he  approaches  the  cup  to  his  lips  his  countenance  assumes  a 
strange  expression,  the  eyes  stand  prominent,  the  features  contract,  the 
limbs  tremble,  and  especially  his  hand  carrying  the  cup,  and  he  tries 
with  a  sudden  movement  to  gulp  down  the  liquid,  but  he  can  not  pass  it 
into  the  pharynx  ;  it  is  violently  rejected  with  a  suffocative  spasm,  and 
he  falls  back  on  the  bed  exhausted.  Presently,  the  appearance  of  water, 
the  reflection  from  a  mirror,  any  impression  suggesting  the  act  of  swal- 
lowing, throws  him  into  a  state  of  apprehension  or  excites  pharyngeal 
spasm.  Meanwhile  a  sense  of  constriction  continues  at  the  throat,  the 
mouth  is  dry  and  parched,  and  he  is  continually  impelled  to  eject  from 
his  fauces,  with  a  harsh,  barking  hawk,  some  viscid  saliva.  It  is  this 
hawking  which  is  vulgarly  supposed  to  be  the  bark  of  a  dog.  It  must 
be  admitted  that  this  is  a  peculiar,  unearthly  hawking,  which,  under 
the  circumstances,  might  seem  like  the  bark  of  a  dog.  The  appearance 
of  the  patient  at  this  time  is  most  striking.  He  is  restless,  his  counte- 
nance anxious,  his  eyes  bright  and  wandering  ;  he  becomes  garrulous, 
and  his  mind  presently  wanders,  and  every  few  minutes  he  hawks  and 
pulls  at  his  throat  as  if  to  remove  some  obstruction.  He  will  not  toler- 
ate the  suggestion  of  liquids,  much  less  their  approach,  and  assumes  a 
hostile  attitude  if  there  is  a  persistent  attempt  to  induce  him  to  try  to 
drink.  On  the  other  hand,  the  mind  may  be  clear,  but  this  must  be 
regarded  as  exceptional,  for,  in  all  the  cases  seen  by  the  author,  the 
patients,  if  not  maniacal,  were  at  least  disordered  in  mind.  Cases  have 
been  reported,  however,  in  which  the  faculties  of  the  mind  were  pre- 
served, in  which  the  patients  not  only  were  fully  aware  of  their  des- 
perate condition,  but  expressed  the  greatest  solicitude  for  their  families 
and  for  those  about  them.  The  author  has  heard  of  one  case  in  which 
the  patient  voluntarily  asked  to  be  restrained  during  the  paroxysm, 
that  he  might  not  do  injury  to  his  attendants.  There  ensues  such  an 
exalted  condition  of  the  reflex  faculty,  at  last,  that  a  breath  of  air  will 


842  ANIMAL  POISONS. 

excite  the  paroxysms,  wkicli  are  not  unlike  those  of  tetanus.  When 
they  come  on,  respiration  is  jerking,  and  then  fixed,  the  vohiutary 
muscles  are  rigid,  breathing  is  suspended,  the  surface  becomes  red  and 
cyanosed,  and  the  action  of  the  heart  is  rapid  and  weak.  They  last 
but  a  few  seconds  at  first,  but  increase  in  duration  and  severity,  and 
are  excited  by  less  and  less  powerful  impressions  toward  the  end. 
Sometimes  there  are  severe  and  persistent  erections  (priapism),  and  in 
women  there  is  nymphomania.  Difficult  urination  is  not  uncommon, 
and  in  some  cases  strangury  is  present. 

Course,  Duration,  and  Termination. — Hydrophobia  is  a  very  acute 
disease.  The  first  stage  does  not  exceed  two  or  three  days,  and  may 
be  but  a  few  hours  in  duration,  the  average  being  about  one  day.  The 
duration  of  the  second  or  hydrophobic  stage  is  similar ;  it  may  last 
two  days,  possibly  three,  but  it  is  usually  ended  in  one,  sometimes  in 
a  few  hours.  The  termination  may  be  by  exhaustion,  the  under  jaw 
drops  and  the  saliva  flows  from  the  corner  of  the  mouth  ;  the  pulse 
becomes  small,  weak,  and  thready,  the  body  is  covered  with  a  cold 
sweat,  the  pupils  are  dilated,  the  eyes  fixed,  the  voice  fails,  and  the 
patient,  after  a  short,  convulsive  trembling,  passes  into  collapse,  and 
dies.  In  other  cases  the  patient  dies  asphyxiated  in  the  paroxysm. 
In  still  others,  general  convulsions  end  the  case.  The  whole  duration 
of  the  disease  is  comprehended  in  about  three  days.  The  prognosis 
of  hydroj)hobia  is  most  unfavorable,  no  cases  of  the  genuine  disease 
having  ever  recovered,  unless  we  may  except  two,  treated  with  woo- 
rara,  lately  reported. 

Diagnosis. — There  is  a  strong  resemblance  between  tetanus  and 
hydrophobia  :  in  both  the  reflex  function  of  the  spinal  cord  is  highly 
excited,  in  both  slight  peripheric  irritation  excites  spasms  ;  but  they 
differ  in  that  hydrophobia  follows  a  bite  of  a  rabid  animal  after  a 
long  period  of  incubation,  and  tetanus  is  caused  by  a  wound  ;  in 
hydrophobia  there  is  a  sense  of  constriction  of  the  fauces — ia  tetanus 
there  is  trismus  ;  hydrophobia  is  of  much  shorter  duration  than  teta- 
nus, is  invariably  fatal,  while  a  considerable  proportion  of  the  cases 
of  tetanus  get  well.  Hydrophobia  may  be  confounded  with  an  hyster- 
ical malady  simulating  it,  but  the  latter  is  accompanied  by  other  hys- 
terical symptoms,  does  not  prove  fatal,  and  there  is  no  history  of  the 
bite  of  a  rabid  animal.  There  are  those  who  maintain  that  hydropho- 
bia— as  a  disease  due  to  a  peculiar  poison  contained  in  the  saliva  of 
the  rabid  dog — ^has  no  real  existence  ;  that  the  poison  is  a  fiction,  and 
that  the  symptoms  supposed  to  be  produced  by  it  are  really  due  to 
the  influence  of  sympathy,  to  the  faculty  of  imitation,  and,  to  the 
imagination,  the  whole  being  intensified  by  morbid  fears.  It  would 
seem  impossible,  on  this  hypothesis,  to  account  for  the  occurrence  of 
this  disease  in  infants  after  being  bitten.  As,  however,  the  imaginary 
disease  is  just  as  fatal  as  the  supposed  genuine  affection,  the  practical 


TRICHINOSIS.  843 

physician  will  be  indifferent  to  the  theories,  and  will  be  as  loath  to 
encounter  the  one  as  the  other. 

Treatment. — When  the  bite  of  a  rabid  animal  has  been  received, 
the  w^ound  should  be  scarified,  cauterized  with  a  hot  iron,  or  every 
part  of  it  touched  with  nitrate  of  silver.  The  success  of  Mr.  Youatt 
has  been  so  great  with  the  nitrate  of  silver  that  severer  applications 
would  seem  to  be  unnecessary.  It  need  hardly  be  stated  that  the  mad- 
stone,  w'hose  virtues  are  firmly  held  by  many,  is  a  purely  imaginary 
remedy.  The  numberless  specifics  which  have  been  proposed  are 
equally  baseless,  and  owe  their  repute  to  the  fact  that,  of  the  large 
number  bitten,  very  few  have  hydrophobia.  There  is  no  specific  to 
prevent  the  disease,  and  we  are  equally  ignorant  of  a  remedy  to  cure 
it.  Of  all  the  remedies  hitherto  proposed,  curare  is  the  only  one  which 
seems  to  possess  any  power  over  hydrophobia.  Tw^o  cases  have  been 
reported  within  the  past  year — one  in  Italy  and  one  in  New  York — in 
which  a  disease,  diagnosticated  as  hydrophobia  by  eminent  practition- 
ers, got  well  under  the  hypodermatic  injections  of  curare.  Chloral, 
chloroform,  gelsemium,  nicotia,  etc.,  may  be  used  to  alleviate  the  dis- 
tress. 


PARASITES. 


TRICHIN.E  AND  TRICHINOSIS. 

Trichina. — This  dangerous  parasite  is  found  in  two  forms,  as  the 
intestinal  trichina  which  is  sexually  mature,  and  as  the  muscle  trichina, 
not  fully  developed,  or  sexually  immature.  The  name  given  by  Pro- 
fessor Owen  {Trichina  spiralis)  is  based  on  the  hair-like  appearance  of 
the  parasite  and  the  spiral  form  assumed  by  it  in  the  muscular  tissue. 
It  is  a  very  smallj  hair-like  worm,  having  a  head  smaller  than  the  rest 
of  the  body,  while  the  caudal  extremity  is  rounded.  The  females  are 
three  or  four  millimetres  long,  and  contain  a  sexual  apparatus  consist- 
ing of  an  ovary,  a  uterus,  and  a  vagina.  Only  a  part  of  the  sexual 
apparatus  exists  in  the  muscle-trichina,  the  rest  being  developed  after 
the  parasite  has  entered  the  intestinal  canal  of  its  host.  It  is  vivipa- 
rous, and  discharges  from  the  vaginal  outlet  about  one  hundred  em- 
bryos a  week,  and  the  birth  of  the  embryos  begins  in  about  a  week 
after  the  female  enters  the  intestine.     As  more  females  than  males  are 


844  PARASITES. 

born,  and  as  successive  f onnation  of  embryos  from  the  eggs  may  take 
jDlace,*  tbe  number  developed  becomes  enormous.  The  male  trichina 
is  one  half  the  size  of  the  female,  and  contains  at  its  caudal  extremity 
the  sexual  apparatus.  The  viable  embryos  discharged  from  the  female 
are  in  lively  motion.  They  do  not  remain  in  the  intestine,  but  begin 
a  process  of  migration  which  only  terminates  when  they  have  reached 
their  habitat  in  the  voluntary  muscles.  The  manner  of  reaching  their 
destination  is  not  known — whether  by  the  blood-vessels,  by  the  lymph- 
channels,  or  by  direct  effort  boring  through  the  intervening  tissues 
until  the  muscles  are  reached.  As  they  have  repeatedly  been  found  in 
the  blood  and  lymph,f  and  in  the  connective  tissue  only  adjacent  to 
muscles,  J  and  as  the  rate  of  migration  is  so  rapid,  it  seems  pretty  cer- 
tain that  the  distribution  is  chiefly  passive  by  the  blood  and  lymph- 
streams.  Endowed  with  a  strange  instinct,  these  parasites,  w^hen  they 
reach  the  muscular  tissue,  stop  their  wanderings,  pierce  the  muscles, 
and  force  their  way  into  the  primitive  fasciculi,  where  they  coil  up. 
The  sarcolemma  of  the  primitive  fasciculus  now  undergoes  thickening, 
a  quantity  of  granular  matter  surrounds  the  parasite,  and  a  number  of 
"  oval,  vesicular-shaped  muscle  nuclei  "  §  develop  on  the  inner  surface 
of  the  capsule  formed  by  the  thickened  sarcolemma.  In  the  process  of 
transplantation  of  the  parasite  from  the  intestinal  canal  to  the  muscle, 
the  parasite  grows  ;  but  it  reaches  the  greatest  size  in  fourteen  days 
after  it  is  established  in  the  muscle.  In  the  intestinal  canal  the  em- 
bryos have  a  very  short  lease  of  life  (five  to  eight  weeks)  ;  but,  safely 
deposited  in  the  muscle,  they  continue  during  the  life  of  their  host 
and  for  a  short  period  after  his  death.  In  the  muscles,  after  a  time, 
the  trichinae  undergo  a  further  change.  Lime-salts  are  deposited  in 
and  about  the  capsule,  and  ultimately  in  the  parasite  itself,  when  mi- 
nute bits  of  lime,  just  visible  to  the  eye,  are  seen  more  or  less  thickly 
distributed  through  the  muscular  tissue.  The  distribution  of  trichina 
is  determined  by  the  migrations  of  its  hosts — the  hog,  the  rat,  and 
man.  This  parasite  has  been  found  in  the  cat  and  other  animals,  and 
has  been  artificially  reared  in  rabbits  and  Guinea-pigs.  In  the  dog, 
however,  it  appears  to  develop  no  further  than  intestinal  trichina,  mi- 
gration of  the  embryos  not  taking  place  in  this  animal.  As  man  and 
the  other  hosts  of  the  parasite  are  to  be  found  everywhere,  so  this  par- 
asite is  universal.  It  is  especially  frequent  in  this  country  in  the  great 
West,  because  of  the  enormous  extent  of  the  pork-traffic.  The  pro- 
portion of  hogs  infected  in  the  West  is  variously  stated,  but  it  is  prob- 

*  Cohnheim,  "  Zur  pathologischen  Anatomie  der  Trichinenkrankheit,"  Virchow's  "  Ar- 
chiv,"  Band  xxxvi,  p.  163. 

f  Virchow,  ibid.,  Band  xxxii,  s.  332,  "  Zur  Trichinenlehre,"  contains  also  a  full  his- 
torical account  of  progress  of  discovery. 

X  Ibid.,  Band  xxxiv,  s.  469. 

§  Heller,  Ziemssen's  "  Cyclopasdia,"  article  "  Migratory  Parasites,"  vol.  iii. 


TRICHINOSIS.  845 

'ably  not  an  exaggeration  to  say  that  from  one  to  twenty  per  cent, 
contain  trichinse.* 

Trichinosis. — The  symptoms  produced  by  trichina,  when  these  para- 
sites reach  the  body  of  man,  are  entitled  trichinosis.  They  are  not 
very  uniform,  but  a  division  into  stages,  based  on  the  several  steps  in 
the  life-history  of  the  trichina,  will  be  convenient.  These  stages  are 
the  intestinal,  the  migration,  and  the  encapsulation.  When  a  piece  of 
pork,  containing  in  every  cubic  inch  eighty  thousand  (Dr.  Sutton)  tri- 
china, is  swallowed,  these  parasites  are  set  free  ;  they  then  complete 
their  sexual  development,  and,  as  each  female  discharges  a  hundred  em- 
bryos, the  intestinal  canal  soon  contains  thousands.  If  few  in  number, 
there  may  be  but  little  disturbance  of  the  canal,  but  usually  more  or 
less  irritation  of  the  stomach  and  intestines  follows  in  a  short  time 
after  the  infected  meat  is  swallowed.  In  a  few  hours  or  in  a  day  or 
two,  some  uneasiness  of  the  stomach  is  felt,  and  in  some  cases  severe 
attacks  of  neuralgia  of  the  solar  plexus  ;  nausea  comes  on,  and  then 
vomiting  occurs.  The  vomiting  may  end  with  the  first  effort  which 
empties  the  stomach,  or  it  may  continue  with  much  retching  and  an- 
guish for  several  days.  The  mouth  feels  pasty,  and  a  subjective  sense 
of  foul  odor  is  also  experienced.  Intestinal  uneasiness  comes  on  with 
the  irritability  of  the  stomach  ;  colic,  more  or  less  distention  of  the 
abdomen,  and  diarrhoea  follow.  The  stools,  at  first  comj)osed  of  faeces 
merely,  become  watery,  light  in  color,  and  may  ultimately  assume  a 
nearly  rice-water  appearance.  This  symptom  is  more  persistent  than 
the  vomiting,  may  continue,  indeed,  for  several  weeks,  and  is  apt  to 
be  exhausting.  Diarrhoea  may  alternate  with  constipation  ;  in  some 
cases  there  is  constipation  only.  When  the  digestive  disorders  have 
persisted  for  several  days,  fever  comes  on  in  the  usual  way,  preceded 
by  shivering  or  a  chill.  It  is  probable  that  the  fever  is  about  coinci- 
dent with  the  birth  of  the  embryos  and  the  beginning  migration.  The 
fever  is  remittent  in  type  in  the  sense  that  typhoid  fever  is,  which  it 
closely  resembles.  In  some  cases  the  type  is  truly  remittent,  with  a 
decided  morning  remission  and  an  evening  exacerbation.  The  pulse  is 
quick,  rather  small,  and  early  shows  a  tendency  to  weakness,  the  range 
being  from  90  to  140.  There  is  intense  thirst,  the  tongue  and  lips  are 
dry,  and  the  face  is  red  and  swollen  (Davaine).  During  the  existence  of 
these  symptoms  the  muscles  of  the  body  generally  are  sore  to  the  touch 
and  are  flabby,  but  this  state  must  not  be  confounded  with  that  con- 
dition of  the  muscles  caused  by  the  migration  of  the  parasites  into 
them  (Heller),  The  migration  period  is  especially  marked  by  the  in- 
vasion of  the  muscles.     The  symptoms  due  to  this  invasion  do  not  occur 

*  The  reader  is  advised  to  consult  an  excellent  paper  by  Dr.  Sutton,  of  Aurora,  Indiana, 
giving  an  account  of  an  outbreak  of  trichinosis,  and  some  general  remarks  on  the  propor- 
tion of  trichinous  pork,  which  he  puts  at  three  to  sixteen  per  cent,  for  southeastern 
Indiana.     (Reprinted  from  "Transactions  of  the  Indiana  State  Medical  Society.") 


346  PARASITES. 

earlier  than  the  tenth  day,  which  allows  three  days  for  the  migration 
from  the  intestine.  The  muscles  are  affected  to  varying  degrees  of 
severity,  doubtless,  according  to  the  number  of  parasites  entering  them. 
There  may  be  only  a  little  soreness,  but  in  decided  cases,  as  might  be 
expected,  the  muscles  are  hard,  swollen,  and  very  tender.  The  muscles 
of  the  extremities,  especially  the  flexors,  are  penetrated,  but  those  of 
the  trunk  also,  only  to  a  less  extent.  In  consequence  of  this,  the  mus- 
cles are  the  seat  of  violent  rheumatoid  pains,  and  motion  increases  the 
distress.  Hence  the  patients  lie  motionless,  with  the  limbs  semiflexed. 
As  the  muscles  of  mastication  and  deglutition  are  also  invaded,  chewing 
and  swallowing  become  diflicult  and  painful  ;  hearing  is  imj)aired  be- 
cause of  invasion  of  the  stapedius  muscle,  and  vision  may  be  double  or 
distorted  because  of  the  penetration  of  the  ocular  muscles.  (Edema  of 
the  eyelids  is  one  of  the  first  symptoms  of  this  period,  and  subsequently 
oedema  of  the  extremities  and  effusion  into  the  peritoneal  cavity  ap- 
pear. For  the  same  reason,  doubtless,  that  the  voluntary  movements 
are  impaired,  the  respiration  is  embarrassed,  and  dyspnoea  is  added  to 
the  other  difiiculties,  and  by  the  end  of  the  fourth  week  a  general  bron- 
chitis, a  pleurisy,  or  a  pneumonia  may  arise  to  complicate  the  case.* 
During  the  development  of  these  formidable  symptoms,  the  mind  may 
continue  undisturbed  ;  in  fact,  a  singular  apathy  takes  possession  ;  in 
other  cases  delirium  occurs,  but  this  may  result  from  the  wakefulness, 
the  coma  vigil,  which  is  so  pronounced  a  feature  of  the  cerebral  condi- 
tion in  many  adults.  In  children  there  is  a  condition  of  somnolence 
throughout.  Various  miliary  and  pustular  eruptions  appear  on  the 
skin,  which  is  extremely  sensitive,  but  the  most  pronounced  symptom 
connected  with  this  organ  is  the  profuse  sweats  which  appear  early 
and  continue  throughout  the  disease.  The  sweats  are  not  critical,  and 
do  not  modify  the  temperature.  Bed-sores  form  to  a  slight  extent,  and 
desquamation  of  the  cuticle  occurs  during  convalescence.  Abortion 
sometimes  takes  place,  but  the  foetus  is  free  from  trichinae  ;  and,  on  the 
other  hand,  pregnancy  may  continue  undisturbed.  The  menses  may 
or  may  not  be  interfered  with,  more  usually  not.  The  course  of  tri- 
chinosis is  greatly  influenced  by  the  number  of  parasites.  A  small 
number  may  cause  a  mere  temporary  diarrhoea  ;  a  large  number  may 
produce  a  violent  gastro-enteritis,  sufficient  to  cause  death  without  the 
migration  into  the  muscular  system  (cases  by  Dr.  Sutton).  In  such 
cases  there  will  occur  the  symptoms  of  gastro-enteritis  only,  and,  after 
death,  intense  hyperaemia,  swelling  of  the  mucous  membrane,  and  de- 
struction of  epithelium  will  be  seen.  The  range  of  temperature  in 
these  cases  is  from  98°  to  100°,  and  the  type  of  the  fever  remittent. 
When  migration  of  a  small  number  of  parasites  occurs,  the  fever  will 
assume  the  typhoid  aspect,  the  temperature  range  from  100°  to  104°, 

*  Davaine,  op.  cit.,  p.  760. 


TRICHINOSIS.  847 

the  usual  muscular  soreness  to  a  small  extent  be  felt,  but  the  most 
pronounced  symptoms  will  be  those  of  inflammation  of  the  gastrc- 
intestinal  canal.  Recovery  may  ensue  in  such  a  case  by  the  encapsu- 
lation of  the  parasites,  and  a  gradual  subsidence  of  the  gastro-enteri- 
tis.  From  three  to  four  months  will  be  occupied  with  such  a  case  from 
its  beginning  to  the  completion  of  convalescence.  In  the  severest 
cases  all  the  symptoms  given  above  will  appear,  and  death  will  take 
place  in  thi-ee  to  four  weeks,  frequently  caused  by  pneumonia.  The 
mortality  from  trichinosis  will  range  from  twenty  to  fifty  per  cent., 
dependent  of  course  on  the  amount  eaten  of  any  given  specimen  of 
trichinous  pork. 

Diagnosis. — Cases  of  trichinosis  are  often  mistaken  for  ileo-colitis 
and  for  typhoid  fever.  From  the  former  it  may  be  differentiated  by 
the  oedema  of  the  eyelids,  the  m.uscular  pains,  and  the  profuse  sweats. 
The  range  of  temjDcrature  being  much  the  same  as  that  of  typhoid, 
the  distinction  between  the  two  must  rest  on  the  muscular  symptoms, 
the  oedema,  the  pain  and  hypersesthesia,  the  profuse  sweats,  and  the 
absence  of  the  muttering  delirium,  the  subsultus,  and  other  nervous 
symptoms.  The  oedema  occurring  in  this  disease,  which  is  general,  is 
separated  from  cardiac  and  renal  dropsy  by  the  absence  of  cardiac 
and  renal  disease,  and  by  the  other  symptoms  pertaining  to  trichinosis. 
In  cases  of  doubt,  the  harpoon  may  be  used  to  take  out  a  bit  of  mus- 
cular tissue  for  examination,  but  this  is  a  measure  of  doubtful  propri- 
ety, because  severe  gastro-enteritis  may  ensue  without  migration.  In 
typical  cases  the  harpoon  would  hardly  be  necessary,  yet  Dr.  Sutton, 
removing  a  small  piece  of  the  gastrocnemius  in  one  of  his  fatal  cases, 
found  it  swarming  with  trichinae,  "  estimated  at  more  than  one  hun- 
dred thousand  to  the  square  inch,"  and  they  were  in  active  motion, 
"  coiling  and  uncoiling." 

Treatment. — Attention  should  be  at  once  directed  to  the  destruc- 
tion and  removal  of  trichinae  in  the  intestinal  canal.  A  variety  of 
remedies  have  been  proposed,  but  no  success  seems  to  have  attended 
any  of  them,  unless  glycerine  may  be  excepted.  The  vomiting  and 
purging,  if  not  excessive,  should  be  promoted  by  diluents.  Glycerine 
and  water,,  which  has  the  power  to  cause  shriveling  and  death  of  the 
parasite,  may  then  be  given — one  part  of  glycerine  to  two  parts  of  wa- 
ter. Carbolic  acid  may  be  administered  both  with  the  view  to  allay 
the  intense  m-itation  and  to  act  on  the  embryos.  "We  venture  to  sug- 
gest a  trial  of  carbolic  acid  and  tincture  of  iodine  for  the  same  purpose. 
Corrosive  sublimate,  arsenic,  picric  acid,  benzine,  and  other  agents  have 
been  used  to  destroy  the  parasites  in  the  intestines,  but  without  results 
(Haller).  Quinia  seemed  to  exercise  a  good  influence  in  Sutton's  cases, 
the  best,  indeed,  of  any  of  the  agents  used.  As  this  remedy  has  a 
toxic  influence  on  the  low  forms  of  life,  it  seems  desirable  to  employ  it 
more  freely  in  future  cases.     If  constipation  be  the  condition,  purga- 


848  PARASITES. 

tives  shoiild  be  administered  without  delay.  The  treatment  to  be  pur- 
sued, when  the  parasites  migrate,  must  be  purely  symptomatic.  The 
obstinate  wakefulness  and  the  pains  will  require  morphia  and  chloral. 
Quinia  and  stimulants  will  be  needed  to  support  the  powers  of  life. 
Milk,  beef-juice,  egg-nogg,  and  other  aliment  must  be  carefully  ad- 
ministered from  the  beginning.  There  is  but  one  point  ia  prophy- 
laxis. Meat  containing  trichinae  should  be  thoroughly  cooked.  As 
the  cases  arising  from  these  parasites  are  caused  by  the  consumption  of 
raw  hams  and  raw  sausage  recently  cured,  this  practice  should  be 
totally  discontinued. 


INDEX 


A  PAGE 

Abscess  of  the  Brain 528 

of  the  Kidney 4ST 

of  the  Liver 151 

•  Perinephric 4S7 

Pharyngeal 12 

Acute  Yellow  Atrophy  of  the  Liver 161 

Adherent  Pericardium 233 

Agraphia 539 

Ague-Cake 192 

Albuminuria 443 

Amyloid  Kidney 461 

Liver 165 

Spleen 193 

Amyotrophic  Lateral  Sclerosis 571 

Aaajmia 213 

Cerebral 493 

Aneurism,  Aortic 291 

Angina  Pectoris 252 

Aortic  InsufiBciency 269 

Lesions 269 

Stenosis 269 

Aphasia 500 

Amnesic 533 

Ataxic 53S 

Apoplexy 504 

Aphthae 1 

Arachnoid,  Cyst  of 513 

Arthritis  Deformans 825 

Rheumatoid 825 

Ascaris  Lumbricoides 120 

Ascites 132,167 

Aspiration 160 

Asthma 416 

Hay 764 

Atelectasis 3S3 

Atrophy  of  Nerves 626 

Acute  Yellow 161 

Autumnal  Catarrh 764 

B 

Basal  Meningitis 520 

Biliary  Calculi 185 

Bile-Ducts,  Occlusion  of . « 184 

Bleeder  Disease 201 

Bleeders 202 

54 


PAGE 

Blepharospasm 685 

Bothriocephalus  Latus 119 

Brain,  Abscess  of 528 

Hyperemia  of. 4S9 

Tumors  of 532 

Breakbone  Fever 724 

Bright's  Disease 443 

Bronchitis,  Acute 403 

Chronic 407 

Croupous 411 

Humid 409 

Broncho-pneumonia 343 

Bronchorrhcea 403,  403 

Brown  Induration 330 

Bulbar  Paralysis 543 

Chronic  Progressive 544 

C 

Calculi,  Biliary 185 

Nephritic 469 

Cancer  of  Intestines 96 

of  Kidney 473 

of  Liver 169 

of  Lung. 398 

of  Pancreas 133 

of  Stomach 41 

Capillary  Bronchitis 343 

Cataleps}- 611 

Catarrh,  Dry 403 

Nasal 437 

Catarrhal  Fever 404 

Pneumonia 343 

Catarrh  of  Intestines 55 

of  Naso-pharyngeal  Space 9 

of  Pharynx U 

of  Stomach 17 

of  Stomach,  Chronic 23 

Caseous  Pneumonia 350 

Cerebral  Anaemia 493 

Embolism, 496 

Haemorrhage 504 

Haemorrhage,  Meningeal 511 

Hj-peraemia 489 

Sclerosia 581 

Syphilis. 390 

Cerebro-spinal  Meningitis ».  T51 


850 


INDEX. 


PAGE    I 

Cervico-occipltal  Neural^a 630 

Cervico-brachial  Neuralgia ; 630 

Cestoda. 113 

Chlorosis 219 

Cholera  Asiatics 727 

Diarrhoea f30 

Morbus 57 

Infantum 60 

Sicca '^31 

Tj'phoid T83 

Cholerine "^30 

Chorea 616 

Cirrhosis  of  the  Liver 145 

Clavus  Hystericus 606 

Colic 100 

Biliary 186 

Kenal 471 

Confluent  Variola . .  .• 657 

Congestion,  Cerebral 489 

Spinal 548 

Constitutional  Diseases 649 

Convulsive  Tic 635 

Coryza 487 

Cow-pox 662 

Croup 431 

Pseudo 429 

Croupous  Bronchitis 411 

Enteritis 79 

Pneumonia -. 325 

Cramp,  Scrivener's 618 

D 

Delirium  Epilepticnm 600 

Dementia  Paralytica 585 

Dengue 724 

Desquamative  Nephritis 443 

Diabetes 828 

Insipidus 837 

Diarrhoea,  Acute 67 

Chronic 67 

Dilatation  of  the  Heart 250 

of  the  (Esophagus 16 

Diphtheria 736 

Diphtheritic  Endocarditis 260 

Disseminated  Sclerosis 581 

Dropsy  of  the  Abdomen 132 

of  the  Brain 518 

of  the  Chest 818 

of  the  Kidney 476 

of  the  Pericardium 240 

Duodenitis 64 

Dysentery 82 

Dyspepsia 24 

Atonic 29 

Dysphagia 14 


Echinococcus  Multilocularis 175 

of  the  Kidney 482 

of  the  Liver 172 

of  the  Lung 400 

of  the  Spleen 193 

Ecstasy 605 

Electrolysis 177 

Embolism 224 


PAGE 

Embolism  of  the  Brain 496 

Infective 502 

Fat 502 

Pigment 501 

Embolic  Pneumonia 841 

Emphysema 386 

Interlobular 386 

Sub-pleural 386 

Substantive 386 

Vicarious 386 

Encephalitis 528 

Endocarditis 256 

Plastic 256 

Ulcerative 260 

Enteralgia 100 

Enteric  Fever 6S9 

Epidemic  Meningitis 751 

Catarrh 761 

Cholera 727 

Epilepsy 595 

— —  Gravior 597 

Mitior 597 

Epistaxis 489 

Eruptive  Fevers 649 

Erysipelas 684 

F 

Facies  Pneumonica 330 

Fevers 689 

Fever,  Intermittent 774 

Malarial 774 

Eemittent 774 

Typhoid 689 

Fibrinous  Pneumonia  825 

Fibroid  Kidney 454 

Phthisis 363 

Fibrous  Tissue  in  Pneumonia 880 

Floating  Kidney 485 

G 

Gall-stones 185 

Gangrene  of  the  Lungs 894 

of  the  Mouth 7 

Gastralgia 80 

Gastritis,  Acute 18 

Chronic 23 

Phlegmonous 23 

Toxic 21 

General  Diseases 649 

Paralysis 585 

German  Measles 672 

Glossitis 5 

Glosso-labio-laryngeal  Paralysis 544 

Gout  (Podagra) 819 

Green-Sickness 219 

Gummata  of  the  Brain 590 

H 

Hsematemesis ;  —  49 

Haemophilia 201 

Haemoptysis 873 

Haemorrhage,  Cerebral 504 

Intestinal 99 

Pulmonary 378 

Spinal 650 


INDEX. 


851 


PAGE 

Ilteinorrhagic  Infarction '. . .  •  2G6 

Variola 658 

Hajinatoma  of  the  Diira  Mater 512 

Uay-Fever 764 

Asthma T64 

Heart,  Diseases  of  the '228,  264 

Dilatation  of 248 

■ •  Hypertrophy  of 248 

Inilammation  of. 242 

Eupture  of.     248 

Valvular  Lesions  of. 264 

nemiplegia 508 

riepatic  Colic ...   186 

Hepatitis,  Interstitial 145 

Suppurative 151 

Hepatization,  Gray 32T 

Eed 827 

Herpes  Zoster 631 

Histrionic  Spasm 635 

Hodgkin's  Disease 804 

Hydatids  of  the  Kidney 482 

of  the  Liver 1T2 

of  the  Lungs 400 

Hydrocephaloid 493 

Hydrocephalus,  Acute 515 

Chronic 517 

Congenital 518 

Hydronephrosis 476 

Hydropericardium 240 

Hydrophobia 839 

Hydropneumothorax 320 

Hydrothorax SIS 

Hypersemia,  Cerebral 489 

Pulmonary 379 

Hypostatic  Pneumonia 880 

Hysteria 603 

Hystero- Epilepsy 605 

I 

Ileitis 67 

lleo-colitis 67 

Infantile  Paralysis 573 

Infarctions 266 

Infarction  of  the  Lung 342 

Inflammation  of  the  Brain 528 

of  the  Dura  Mater 512 

of  the  Meninges  (Cerebral) 524 

of  the  Nerves 624 

Influenza 761 

Insufficiency,  Valvular 264 

Intercostal  Neuralgia 680 

Intermittent  Fever 774 

Intestines,  Diseases  of. 55 

Catarrh  of 55 

Hsemorrhage  of 99 

Obstruction  of 102 

Intestinal  Calculi 106 

Parasites 113 

Intussusception 104 

Invagination  of  Bowel 105 

J 
Jaundice 168, 171,  182 

K 
Kidney,  Amyloid 461 


Kidney,  Bright's  Disease  of 443 

Congestion  of  (Active) 441 

Congestion  of  (Passive) 442 

Cancer  of 478 

Diseases  of 441 

Hydatids  of 482 

Large  White '. 443 

Movable 485 

Tuberculosis  of. 481 


Lardaceous  Liver 165 

Laryngismus  Stridulus 429 

Laryngitis,  Acute 422 

Chronic 424 

Croupous 431 

Larynx,  Diseases  of 422 

Infiltration  of 426 

Leucocythemia 194 

Leuc»mia 194 

Liver,  Acute  Yellow  Atrophy  of 161 

Amyloid  Disease  of. 165 

——  Congestion  of 140 

Cancer  of 169 

Hydatids  of. 172 

Lockjaw 620 

Lumbo-abdominal  Neuralgia 630 

Lungs,  Cancer  of 398 

Congestion  of 379 

Consumption  of  the  350 

Echinococcus  of. 400 

Gangrene  of. 894 

(Edema  of 379 

Lymphadenoma 804 

Lysis 834 

M 

Malarial  Diseases 7T4 

Fevers 774 

I  Malignant  Anaemia 222 

Measles 666 

Medulla  Oblongata,  Diseases  of  the 641 

Haemorrhage  of 541 

Inflammation  of,  Acute 543 

Inflammation  of,  Chronic 544 

Occlusion  of  Vessels 548 

Melanffimia 200 

Membranous  Croup 481 

Meningeal  Hjemorrhage 511 

Meningitis,  Acute 524 

Chronic 52T 

Spinal 553 

Tubercular 520 

Miasmatic  Diseases 727 

Miliary  Tuberculosis 795 

Mimetic  Spasm 685 

Mitral  Insuflttciency 274 

Lesions 272 

Stenosis 272 

Mumps 771 

Muguet 3 

Myelitis,  Acute 557 

Chronic 561 

Myocarditis !i!42 


852 


INDEX. 


PAGE 

N 

Nasal  Catarrh 437 

Haemorrhage 439 

Naso-pharyngeal  Catarrh 9 

Nematoda 113 

Nephritis 443 

Parenchymotous 443 

Interstitial 454 

Nephrolithiasis 469 

Nerves,  Atrophy  of 626 

Inflammation  of 624 

Neuralgia 626 

Cervico-occipital 630 

Cervico-brachial 630 

of  the  Fifth  Nerve 626 

Intercostal 630 

Lnmbo-abdominal 630 

Neuritis  Ascendens 624 

Descendens 624 

Neuroses,  Cerebro-spinal 595 

Noma T 

O 

Obstruction  of  the  Intestines 102,  106 

of  the  Bronchi 415 

Occlusion  of  Biliary  Passages 184 

of  Cerebral  Vessels 496,  501,  502,  543 

CEdema  of  the  Glottis 426 

of  the  Lungs 379 

OEsophagitis 13 

Oligemia 213 

Oxyurus  Vermicularis 123 

P 

Pachymeningitis 512 

Spinalis 552 

Pancreas,  Calculi  of. 140 

Cancer  of. 138 

Cysts  of 140 

Pancreatitis 137 

Paracentesis  Thoracis 317 

Paralysis  Agitans 612 

Infantile 573 

Parasites,  Intestinal 113 

Parenchymatous  Nephritis 443 

Chronic 450 

Parotiditis 771 

PeUeterine 118 

Pericardium,  Adhesions  of 238 

Dropsy  of. 240 

Inflammation  of. 228 

Pericarditis 228 

Perinephric  Abscess 487 

Perinephritis 487 

Peritonitis 125 

Chronic 130 

Suppurative 136 

Tubercular 130 

Perityphlitis 74 

Pertussis 768 

Pharyngeal  Catarrh 11 

Phthisis 850 

Caseous 350 

Fibroid 363 

Tubercular 355 


PAGE 

Pigment  Embolisms 200,  501 

Pleurisy 804 

Chronic 808 

Hagmorrhagic 806 

Purulent 306 

Pleuritis 804 

Pneumonia 325 

Catarrhal 843 

Croupous 825 

Fibrinous 825 

Pneumonitis 825 

Pneumothorax 820 

Podagra 819 

PoliomyeUtis  Anterior  Acuta 573 

Polydipsia 837 

Polyuria 887 

Portal  Vein,  Suppurative  Inflammation  of 179 

Posterior  Spinal  Sclerosis 564 

Proctitis 75 

Progressive  Anaemia 222 

—  Locomotor  Ataxia 564 

Muscular  Atrophy 576 

Muscular  Atrophy,  Pseudo-Hyp ertrophic.  580 

Pulmonary  Emphysema 886 

Haemorrhage 873 

Valves,  Lesions  of. 277 

Purpura 210 

Haemorrhagica 210 

Simplex 210 

Pyelitis 460 

Pyelonephritis 466 

Q 

Quinia  as  an  Antipyretic 702 

in  Fevers  702 

as  a  Prophylactic 786 

E 

Eabies 839 

Eectum,  Catarrh  of 75 

Eegurgitation,  Aortic 269 

Mitral 274 

Eelapsing  Fever 710 

Eemittent  Fever 774 

Eenal  Calculi 469 

CoUc 471 

Eheumatic  Gout 825 

Eheumatoid  Arthritis 825 

Eheumatism,  Acute 809 

Chronic 817 

Pickets 798 

Eoseola 672 

Eoetheki 672 

Eound  "Worms 120 

Eubeola 666 

Eupture  of  the  Heart 248 


Scarlatina 678 

Scarlet  Fever 678 

Sciatica 631 

Sclerosis  of  the  Brain  and  Cord 581 

of  the  Kidney 464 

of  the  Liver 145 

of  the  Spine 681 


INDEX. 


853 


PAGE 

Scorbutus 205 

8cr6fula 790 

Scurvy. 205 

Shaking  Palsy C12 

BmaU-pox 649 

Spasm  of  the  Eyelids .  iV.'5 

of  the  Foco G;35 

of  the  Glottis 4->9 

Histrionic 635 

Spinal  Cord,  Hypersemia  of 543 

Inflammation  of 55T 

Spinal  Meningitis 553 

Spleen,  Amyloid  Disease  of. 193 

Echinococcus  of 193 

Enlargement  of 191 

Misplaced 192 

Splenitis 189 

Bplenization  of  the  Lung 380 

Stenosis  of  the  Aortic  Orifice 269 

of  Bronchi 415 

of  Mitral  Orifice 272 

of  (Esophagus 15 

Stomach,  Dilatation  of 53 

Diseases  of 17 

Stomatitis 1 

— —  Mercurial 1 

Struma 790 

Suppuration  of  the  Tongue 6 

Syphilis  of  the  Nervous  System 590 

'Syphiloma  of  the  Brain 590 

of  the  Cord 593 

of  the  Nerves 595 

T 

Tabes  Dorsalis 564 

Taenia  Saginata T 116 

Solium 116 

Tape-worm 114 

Terminal  Arteries 261,  266 

Tetanus .620 

Thrombosis 224 

of  the  Brain 496 

of  the  Portal  Vein 178 

Tic-Douloureu.x 626 

Thread-worms 123 

Tongue,  Inflammation  of 5 

Suppuration  of 6 


PAGH 

Torsion  of  the  Bowel 104 

Torticollis 68C 

Tremor 683 

Trichinm 648 

Trichinosis 848 

Tricuspid  Lesions 275 

Trismus 620 

Neonatorum 620 

Tubercular  Consumption 355 

Meningitis 520 

Tuberculosis,  Acute 795 

Tuberculous  Ulcers  of  Intestines 95 

Tumors  of  the  Brain 532 

Typhlitis 69 

Typhoid  Fever 689 

Typhus  Fever 705 

U 

Ulcer  of  Csecnm 90 

— —  of  Duodenum 91 

of  Intestines 91 

of  Stomach 88 

Ulcerative  Endocarditis 260 

Urinary  Calculi 469 

V 

Vaccinia 662 

Vaccination 662 

Valvular  Lesions 264 

Varicella 665 

Variola 649 

Varioloid 659 

W 

Wandering  Kidney 485 

Spleen 192 

Waxy  Liver 165 

Whooplng-Cough 768 

Winter  Fever 825 

Worms,  Intestinal 113 

Writer's  Cramp 618 

Wry  Neck 636 

Y 

Yellow  Atrophy  of  the  Liver 161 

Yellow  Fever 715 


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